sent for progressive weight loss and choking at mealtimes. His medical history is complex. He has a rare genetic syndrome that involves progressive dystonia seen in his limbs and bulbar muscles. This has rendered his speech unintelligible. His cognitive function permits conversations using a text-to-speech applica­tion on his phone. He attends a day treatment program. Each morning his mother packs his lunch, which typically returns unopened. Due to weight loss, his gastroenterologist advised daily 530-calorie BOOST. This did little to stabilize his weight loss, which in its current state resulted in a low body mass index (BMI) of 16. An oral-motor exam demonstrated severe tongue atrophy, fasciculations, and immobil- ity. His mother prepared lunches of sandwiches, carrots, chips, and cookies. These textures were tested during a FEES examination. His oral phase was protracted and caused fatigue. Once Charlie attempted to swallow, his pharyngeal squeeze was ineffective, so there were significant residuals. Charlie routinely gagged and spit out solids. Thin and thick liquids were consumed with a timely reflexive swallow. There was no penetration or aspiration. Charlie also reported less fear when drinking versus eating. After a lengthy discussion with Charlie’s family and medical team, he ultimately underwent PEG placement. Charlie’s mother described this as a relief; it offloaded her persistent stress that her