Feeding and Swallowing Disorders

Feeding disorders include difficulty getting ready to suck, chew, or swallow food. Feeding disorders typically occur in children, such as when a child cannot completely close her lips to prevent food from falling out. Feeding disorders also encompasses the sensory aversion some people have to textures of foods.  Swallowing disorders, also called dysphagia, more typically occur in adults. Swallowing disorders can occur at different stages in the swallowing process.

Feeding Disorders

Feeding therapy supports infants and children dealing with a wide array of food-related challenges.  These can include:

• Delayed feeding development
• Oral-motor deficits
• Limited food intake
• Food refusal
• Food selectivity by type and/or texture
• Dysphagia (swallowing disorder)
• Food or swallowing aversion
• Mealtime tantrums

How do I know if my child has a problem?

Feeding disorders can be mild to severe in nature. Signs that indicate that your child may have a feeding disorder include refusal to eat certain textures of food (i.e. only eating crunchy cereals), long meal times (i.e. more than 30 minutes), difficulty chewing, gagging or coughing during meals, frequently spitting up or vomiting, or slow weight gain or growth.

Depending on the nature of your concerns, your child will be evaluated by either an occupational therapist or a speech-language pathologist. Based on the results of the evaluation, a comprehensive plan is created that encompasses clinic-based therapy and a plan to be implemented at home.

How can feeding therapy help?

Feeding therapy is critical to address nutritional and growth concerns, reduce or eliminate concerns related to aspiration of food or liquid, and encourage a life-long healthy relationship with food and meals. Feeding therapy addresses all aspects of feeding and swallowing, depending on the need of your child, and can include exposure to new textures of foods, desentization to adverse foods, and modified swallowing techniques. Additionally, parents are provided training and support to reduce anxiety and power struggles that may occur during at-home meal times.

Swallowing Disorders

Dysphagia, or swallowing disorder, is any abnormality occurring during this process. It can occur due to a stroke, Parkinson’s disease, Lou Gehrig’s disease, or any other condition affecting the neuromuscular structures in the head and neck. Because the structures involved in breathing and swallowing are in such close proximity, ingestion of food particles into the airway is a major concern. The most severe cases of dysphagia can lead to aspiration pneumonia due to bacteria in the lungs from an abnormal swallow which, not uncommonly, can lead to death.

To understand the disorder of swallowing, it is important to understand the basic anatomy and the process of a normal swallow. Usually the lips and tongue hold food and aid in pushing it to the back of the mouth. The soft palate, or back of the throat, pushes down on the back of the tongue to help form the food into a bolus, or ball, while the hyoid bone, a thin bone in your throat, elevates and moves forward. This movement, along with the contraction of several muscles, allows the food to pass over the epiglottis, the flap which covers the airway. The bolus and food then move past the covered larynx (voice box) and into the pharynx (back throat).

How do I know if there is a problem with my swallowing?

Symptoms of a swallowing disorder include the inability to hold food in the mouth, difficulty moving food from the front to the back of the mouth, and “pocketing” food particles in the mouth after the swallow process is complete. Some patients may feel like food is “stuck” in the throat, have pain during swallowing, cough before, after, or during the swallow, or demonstrate esophageal reflux. If any of these signs occur, a dysphagia evaluation is recommended to ensure safe nutritional intake. In the event that a person is hospitalized after a stroke, the physician may request a speech-language pathologist to evaluate swallow safety before discharge. Not all symptoms present themselves immediately after an accident. However, if they arise as the patient’s condition changes, an outpatient evaluation can easily be performed.

What happens next?

A complete diagnostic evaluation is the first step in developing a safe and effective therapy plan. Initially an extensive bedside exam is performed to assess the musculature of the lips, cheeks, and tongue. The coordination and range of motion in these structures dictates the safest diet to ingest. If problems are suspected after the food has left the oral cavity, a Modified Barium Swallow (MBS) test is commonly recommended. This X-ray exam involves eating food or liquid that contains barium, which “highlights” the food and allows it to be seen on the X-ray as it travels from the mouth to the stomach. This test is essential for determining whether or not an individual is aspirating or passing food particles into the airway. It also allows speech therapists to pinpoint the location of breakdown and identify the affected muscles and nerves, as well as clearly define the type of therapy most beneficial to the patient.

Therapy can be a combination of strengthening muscle range and coordination, increasing sensitivity to the presence of food, diet manipulation, and patient education and training. Each speech therapist has a unique approach to addressing these issues, but diet manipulation uses standard categories to establish appropriate food consistency.

Broken into three basic levels, food diets are referred to as puree, mechanical soft, or regular. Puree diets may include applesauce, pudding, or anything that can be blended into that consistency. This diet is considered the easiest to ingest because it requires minimal chewing or bolus formation. Mechanical soft diets contain items of a “mashed potato” consistency which are often put in gravy to lubricate the swallow. These diets are recommended for patients with more muscle coordination and control than those on a puree diet. A regular diet indicates that a patient can safely manipulate any solid consistency, but does not mean that dysphagia is not present.

Swallowing difficulties may occur with liquids alone, or in combination with solids. Liquid consistencies are divided based on thickness, and are categorized as thin, nectar thick, or honey thick. Water is the guide used for “thin,” and moves quickly through the mouth to the stomach. A patient who is slow in covering the airway during the swallow may be restricted from thin liquids in order to reduce the risk of aspiration. Nectar thick consistency is that of apricot nectar. Honey thick liquids resemble honey, and move slowest through the oral cavity. The slower a liquid moves, the more time a patient has to prepare for each stage of the swallow and reduce risk of aspiration. By adding a powdered substance known as “Thick It” to liquid, any consistency can be established. For patients requiring diet modification after a hospital stay, “Thick It” can be purchased over the counter and added to foods as needed.

For individuals who aspirate on the Modified Barium Swallow (MBS) exam, eating is not safe. These patients are given nothing by mouth. Medical professionals on the patient’s rehabilitation team discuss alternative methods of feeding and choose one of two nutrition options. Nutrition can be passed through a nasogastric tube or a percutaneous endoscopic gastrostomy (PEG) tube. A nasogastric tube is placed in the nostril, through the nasal cavity and along the back of the throat until it enters the pharynx, bypassing the swallowing mechanism. It is a temporary solution that provides nutrition until the patient’s status has improved to an independent swallow. A PEG tube is surgically placed in the small intestine and food is passed through it directly into the stomach. It is considered a less temporary method of feeding.

What can friends and family do to help?

The most important thing friends and family can do to help individuals with dysphagia is support them. Attend therapy sessions and learn how to prepare safe foods for your loved one. Encourage him or her to stay educated and respect the risks involved when eating is unsafe. Swallowing disorders can present many complicated challenges but a supportive network of family members and friends provides the best possible outcomes.

How can swallowing therapy help?

Therapy consists of a person learning compensatory strategies for swallowing, understanding about the different types of liquids and solids, and learning how to modify solids and liquids to better facilitate successful swallowing. The therapist makes recommendations and observes the client eating food and drinking liquids to assure successful swallowing.