older child or adolescent with cognitive limitations could require vigilant meal supervision to circum­vent swallowing patterns that are unsafe. Consider nonverbal children with severe intellectual deficits whose only pleasure is eating. They may exhibit impulsive behavior such as eating solids too rapidly without properly chewing. Pacing techniques using bite → sip → bite → sip may be a simple cadence to implement that reduces the likelihood of chok­ing. Smaller utensils and cutting food in advance are other external means of keeping the child on the least-restrictive diet. If children do not exhibit texture preference and they are ultimately less likely to aspirate with a diet downgrade, such as IDDSI 0 and 7 to IDDSI 2 and 3, this could be a feasible strategy to keep them safe at meals. It may also be a technique that does not require such intensive supervision. Each family will present with nuanced concerns that can be addressed with creative inter­ventions. Consider intellectual status when per­forming instrumental swallowing exams. Some may tolerate FEES without difficulty, while others may require a fluoroscopic study for better cooperation as swallowing strategies are trialed.