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— IDDSI Levels
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Types of Food
Breast milk or formula
IDDSI Level 0–1 only
Coordinated suck/swallow/breathing at
34–37 weeks
Feeding readiness: gags with gavage
tube insertion, competently swallows
oral secretions, demonstrates rhythmic
nonnutritive suck
Breast milk or formula
IDDSI Level 0–1 only
Rhythmic sucking pattern (average
1 suck burst/s for nutritive sucking,
2sucks/s for nonnutritive suck)
Oral-pharyngeal area is shared for
feeding and breathing
Hand to mouth activity
Hand reaching toward bottle
Table 14– 3. Pediatric Feeding Skills Development
Gag reflex develops
usually around 32
weeks’ gestation
Lower tone
More extension
Age Positional Stability Reflexes Feeding Skills
Preterm
infants
(34–36
334
Suck reflex
functionally mature
at 32–34 weeks
Rooting reflex elicited
at 32 weeks
Gag reflex
Rooting reflex
Reduced buccal pads
Reduced cup shape of
tongue
weeks)
Buccal pads present
Lip closure
Newborn
to 3
Tongue protrusion
reflex
Cup-shaped tongue
facilitates transfer of
months
(full-term)
Biting reflex
liquid to pharynx
Suck/swallow reflex
Oral and pharyngeal
structural mobility
support both
respiration and feeding
Limited neck stability
Breast milk or formula
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May begin to introduce solid
foods with spoon
IDDSI Level 0–4
Breast milk or formula
Finger foods
Crackers, toast
Soft fruits and vegetables
Strained foods
IDDSI Level 0–6 (with caution)
Breast milk or formula
Soft table foods
continues
IDDSI Level 0–6
Beginning of up-and-down chewing
(munching)
Lateral tongue movement
Lip closure around spoon begins
primitive reflexes are
disappearing except
Transitional period —
Increasing stability of
4 to 6
for gag reflex
neck and shoulders
Lower lip positions
around spoon
months
Both hands to hold bottle
Cup drinking introduced
Tongue fills less space
in oral cavity, allowing
for greater mobility and
posterior positional
shift
More mature lip movement, mobility, and
stabilization
Tongue lateralization present
Gag reflex similar to
adult
Teeth eruption (central
and lateral incisors)
Upper lip more mobility
7 to 9
months
Rotary (diagonal) chewing begins
Assisting with spoon
Beginning to drink from cup held by
caregiver
to stabilize spoon
feeding
Holding bottle or cup
Liquid loss from mouth with cup drinking
may be noted
Pincer grasp
Self-feeding by grasping spoon with
whole hand
Gag reflex Continued maturation of feeding skills
Molar eruption
Corners of lips and
cheek are drawn
inward during
chewing. The cheeks
are used to control
and move food
10 to 12
months
Holds cup with two hands
Has four to five consecutive swallows
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Types of Food — IDDSI Levels
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Whole cow’s milk
Solid foods
Chopped foods
IDDSI Level 0–6
Rotary chewing becomes more mature
Increasing control of liquid during cup
drinking
Bites down on rim of cup
Uses long sequence of drinking at one
time
Begins to develop controlled bite
Chews with lips closed
Chopped, fine food to regular
Firmer meats for chewing can
be introduced
cup drinking
Child cleans lip with tongue
IDDSI Level 0–6
May begin to transfer food from one side
of mouth to other side
Rotary chewing is mature
Begin to suck with a straw
Skills are refined for independent feeding
continued
Table 14– 3.
Gag reflex Up-and-down jaw movement stops
External jaw
stabilization begins
Full eruption of incisors
Age Positional Stability Reflexes Feeding Skills
13 to 18
months
and molars increases
336
the vertical diameter of
oral cavity
Gag reflex No longer uses bite to stabilize cup for
19 to 24
months
Regular table food. Concerns
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regarding judgment and
distractibility may limit foods
offered.
IDDSI Level 0–7
Skills continue refinement (child
develops finer control) as sensory-motor
experience continues to shape central
representation of feeding.
Gag reflex is elicited
from the posterior
third of the tongue
(as in adults) and by
adulthood can be
under some voluntary
and adaptation:
Anatomic changes
continue to place
demands on oral
25 to 36
months
continued eruption
sensory-motor agility
control.
of molars, inferior-
anterior growth of
the mandible, and
descent of the hyoid
and larynx with
the hypopharynx.
Changes continue
through puberty.
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
It may occur in children who have experienced prolonged periods of restricted
eating or drinking, children who have
experienced discomfort associated with
feeding or even medical intervention,
or children who have impaired oral
sensory-motor feeding skills.
When assessing the mouth and oral
cavity look at the structure and movement of the mouth and oral cavity,
including:
n
Gum and mucous membranes
n
Palate
n
Presence of dentition
n
Airway status, including jaw size
and presence of tonsils
n
Tongue
The gums are checked for hyperplasia (i.e., excessive growth of gum
tissue) because of possible side effects
of anticonvulsants, although not such
a feature with the modern anticonvulsant drugs. Both the gums and mucous
membranes are observed for bleeding,
sores, and hydration status. The palate is checked for architecture and cleft
deformities. If teeth are present, they
should be observed for number, caries,
grinding, and occlusion.
During the oral assessment, the bite
reflex is assessed. The bite reflex is demonstrated during infancy by an up-anddown movement of the jaw. Pressure on
the anterior and lateral aspects of the
gums elicits this response. It usually
disappears between 3 and 5 months.
Next assess the gag reflex. The gag
reflex is present at birth and throughout our lives. It is elicited by placing a
tongue blade on the anterior one third
of the tongue and gently “walking
back” until the tongue “humps” or ele-
vates. This is one of the signs indicating
the child can protect the airway during
swallowing. An absent or diminished
gag reflex may lead to aspiration.
Both the sensory (did the child gag?)
and the motor response (how strong
was the response?) should be noted.
At this point, it is usually necessary
to soothe and quiet the infant before
proceeding.
Once the infant is quiet, assess the
protrusion reflex. The tongue protrusion reflex is present during the first
4 months. This immature tongue movement pushes solid food out of the
mouth when it is placed on the anterior
part of the tongue. It can be assessed
by placing a small quantity of food on
the tongue and observing the tongue
movement. The tongue protrusion
reflex is one of the reasons why infants
are not fed solid foods for the first 4 to
6 months of life.
5 to 7 Months
This is a transitional time for the maturing infant as they begin losing the
primitive reflexes for rooting, sucking,
biting, and tongue protrusion and their
anatomy changes with lengthening of
the pharynx and descending of the
larynx.
Again, assess the structure and
movement of the mouth and oral cavity, including:
n
Rooting reflex (disappearing at
age 3–5 months)
n
Suck reflex (disappearing at ap-
proximately age 6 months)
n
Tongue movements (protrusion
reflex disappearing at age 4 months)
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n
Bite reflex (disappearing at 3–5
months)
n
Gag reflex (lifelong)
8 to 12 Months
During this stage, primitive reflexes
disappear. First assess the mouth and
oral cavity, including both structure
and function, as mentioned previously.
Teeth may be present, most notably,
deciduous or primary central incisors. Lateral incisors may be present or
erupting. Voluntary tongue movements
may be observed. Assess the gag reflex.
FEEDING SKILLS ASSESSMENT
The clinical team needs to bring with
them keen observational skills. After a
general oral sensory-motor examination, a meal observation is required. It
is important to observe the child in the
most natural setting possible, and if different problems occur in different environments, more than one observation
may be required, for example, a home
visit and a school visit. It is important to
replicate normal routines wherever possible to ensure the observation reflects
a normal meal. Observing feeding/eating at a normal mealtime is preferable.
Using a child’s usual seating, being fed
by their primary feeder, and presenting
their usual food/fluids from their usual
utensils is advised. Video recording of
mealtime observations may be useful for further review and monitoring
change. The meal observation is a time
for assessment but also problem solving. Modifications in feeding/eating
may be trialed, for example, position-
ing, pacing, a different teat/utensil, or
a different texture/viscosity.
Birth to 5 Months
A meal observation in a young infant
should consider suck/swallow/breathe
competency, maintenance of physiologic stability, and any signs of anatomical or physiological deficits (Thoyre
et al., 2014). Can the infant coordinate
swallowing with breathing efficiently
throughout a feed? Can the infant
maintain healthy oxygen saturation
and heart rate throughout a meal?
Lip, tongue, and jaw closure should be
considered. Inadequate lip or jaw closure makes eating and swallowing difficult because of an inability to create
adequate seal around the bottle/nipple, resulting in insufficient negative
intraoral pressures. Impaired tongue
mobility affects both intraoral pressure and oral transfer of a food bolus
before swallow. The swallow reflex can
be observed or felt by the upward and
forward movement of the cricoid cartilage during the introduction of liquids
listening for any signs of aspiration (see
aspiration section later in the chapter).
If an incompetent pharyngeal swallow
or respiratory changes are suspected,
or the child is at risk for pulmonary
compromise, pharyngeal imaging may
need to be considered (see criteria for
dynamic swallow study [Chapters 6–8]).
An efficient feed should normally
last 15 to 30 minutes. An inefficient
feed, where the infant continues to feed
but the volume per minute is low, may
suggest oromotor impairment. The clinician must look out for short or prolonged feeds as well as fatigue effects.
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
The ability to sustain engagement in the
task should be observed. Once fluid/
food is introduced, the clinician must
look for signs of diminished responses,
hyperactive responses, and oral sensory defensiveness (Arvedson & Brodsky, 2002).
5 to 7 Months
Besides assessing for previous physical
findings, whenever possible, observe
for maturing tongue movements. Children at this development stage begin
gaining voluntary oral control by alerting with mouth opening at the sight of
food, elevating the tongue, and beginning to manipulate food orally and
start to initiate self-feeding behaviors.
To assess voluntary oral control, it
will be necessary to offer solid pureed
food. When the food is first offered,
voluntary alerting and mouth opening
to accept food are seen in an infant at
this stage. The infant may become very
active and excited at the sight of food.
It may be important to schedule the
feeding assessment near or at a regularly scheduled mealtime to assess the
infant’s genuine response to food at a
time normally fed. Tongue elevation
(tongue pushes back and touches palate) and lateral (side-to-side) movements should be observed. If tongue
elevation is not noted during the oral
assessment, it can be assessed by offering food with a spoon. Tongue elevation clears food from the roof of the
mouth and is necessary for the infant to
eat and swallow pureed foods. Tongue
elevation will be seen when the infant
loses the protrusion reflex and gains
the ability to manipulate and swallow
pureed foods given by spoon. The swal-
lowing reflex is assessed while the child
is eating.
Food manipulation or munching
involve jaw movements and tongue
lateralization (the ability of the tongue
to move side to side). Jaw movements
mash the food. Tongue lateralization
enables the food to be moved to and
from the gums and teeth for swallowing.
Many normally developing children will
experiment with finger food and soft
solids during this stage. The beginning
stages of food manipulation or chewing
start at 5 months of age with voluntary
up-and-down jaw movements (“vertical
munch”). Tongue lateralization begins
at 6 to 7 months of age. The up-anddown jaw movements are followed
by lateral jaw movements (and later
by mature rotary movements: “rotary
grind”). During this initial stage, upand-down and lateral jaw movements,
with tongue lateralization, are normal.
Food manipulation can be evaluated by
observing the child’s control of food.
Jaw movements and tongue lateralization need to be noted. Tongue lateralization, if not observed during oral cavity
assessment, can be judged by placing
a small quantity of food on the gums,
on the teeth, or in the lateral oral cavity and observing the child’s ability to
mash or manipulate the food and then
move it to the tongue for swallowing.
Inadequate food manipulation or lack
of tongue lateralization makes eating
textured food difficult or impossible.
Independence in feeding may be
assessed at this stage of development.
Self-feeding at this stage is demonstrated by:
n
Increasing midline stability to sit
independently and begin to hold
a bottle or cup
14. PEDIATRIC CLINICAL FEEDING ASSESSMENT
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341
n
The palmar grasp (the child’s abil-
ity to pick up large pieces of food
between the thumb and palm)
n
Gross motor skills, including vol-
untary shoulder adduction and
abduction, and elbow flexion with
supination and pronation
8 to 12 Months
During this stage, there is a continued
maturing of feeding skills, including
food manipulation, chewing skills, and
self-feeding skills.
Observations at this development
stage are:
n
Voluntary oral control
n
Voluntary alerting
n
Tongue elevation
n
Food manipulation or chewing
n
Self-feeding skills — finger feeding,
cup drinking, and spoon feeding
The up-and-down and lateral chewing now progresses to the beginning of
a mature rotary-type movement. The
child’s increasing number of teeth will
enable them to handle more food textures and larger pieces of food, though
true tearing of food may coincide more
with eruption of the lateral canines at 16
to 23 months of age, and rotary chewing usually coincides more with eruption of the first molars, from 13 to 19
months of age. The swallowing reflex is
assessed while the child is eating.
Self-feeding skills in this age group
are demonstrated by:
n
Midline stability to sit alone in the
chair and to hold a bottle or cup.
n
Maturing gross motor control
enables easier cup holding with
less spillage and smoother control
of food from hand to mouth.
n
Fine motor skills to self-feed prog-
ress from palmer to pincer grasp.
The pincer grasp allows the child
to pick up food between their
thumb and finger, enabling selffeeding with utensils and the ability to self-feed bite-sized pieces of
food.
n
Independent eating is increas-
ingly occurring as development
progresses.
Older Children
Feeding skills acquired during the first
year of life are further refined during
the toddler years. These are primarily chewing and further development
of fine motor skills and control. In the
older child, dentition plays a more
important role in mealtime competency, and occlusion patterns and dental health need to be assessed.
PSYCHOSOCIAL INTERACTIONAL
FEEDING ASSESSMENT
The relationship and interaction between the child and parent or caregiver are extremely important. In recent
years, there has been increased interest
in the impact of parental behaviors on
children’s feeding development and
eating habits, in particular the development of food aversion/restrictive food
intake (McPhie et al., 2014). Parents’
own eating habits, their feeding style,
and regular stressful mealtimes have all
been found to have a long-term effect
on children’s eating habits (Thorsteinsdottir et al., 2021). This is particularly
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
important in children with neurodevelopmental disorders and neurodiversity (e.g., autism spectrum disorders [ASDs]) who have been shown to
accept fewer food items than neurotypical children and not “grow out” of this
fussy eating later in childhood in the
same way neurotypical children typically do (Thorsteinsdottir et al., 2021).
A full discussion of this complex topic
and the rapidly emerging evidence base
is beyond this chapter. However, tools
such as the Parent-Child Feeding Scale
(Huber, 1991) may be useful for clinicians who have concerns. Tools like this
offer information about the relationship
between the parent and child during
the feeding. The Parent-Child Feeding
Scale focuses on the parent’s sensitivity to the child’s cues, distress, socialemotional and cognitive growth fostering behaviors, and the child’s clarity of
cues and responsiveness to the parent.
In addition to observing interaction patterns, it is critical to note the behavior
of the child before, during, and after the
mealtime experience. The child’s cues
of pleasure or distress are fundamental to determining how and where the
feeding process is interrupted.
quality changes, swallows, apnea with
bradycardia, cyanosis, stridor, hoarseness, and/or obstructive inspiratory
efforts (Thach, 2007) (see Table14–2).
With this in mind, silent aspiration is
relatively common in a pediatric population (Figure 14–1), either due to
prematurity or sensorimotor deficits
such as in cerebral palsy (Arvedson et
al., 1994). If in doubt, an instrumental
assessment is advisable.
INSTRUMENTAL ASSESSMENT
While the clinical feeding assessment
is critical for assessing medical and
developmental history, feeding behaviors, and oral skills, there are often
times where instrumental assessment
is required to investigate anatomy,
physiology, biomechanics, and safety
ASPIRATION
A child’s response to an aspiration
event adapts with maturity. The mature
adult’s response to aspiration of food
or drink is typically a cough. There is
no place for a cough reflex in the fluidfilled lungs of a fetus in utero. In premature children, the cough reflex is, therefore, often not fully developed. Until
the cough reflex matures, typical signs
of aspiration during feeds may include
changes in respiration, gagging, vocal
Figure 14–1. Sixteen-month-old child aspi-
rating on fluoroscopic swallow study.
14. PEDIATRIC CLINICAL FEEDING ASSESSMENT
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(DeMatteo et al., 2005). While the
child’s oral phase can be observed
during a feeding assessment, the pharyngeal phase, esophageal phase, and
airway invasion can only be inferred
(Arvedson & Brodsky, 2002; Arvedson et al., 1994; DeMatteo et al., 2005).
Instrumental assessment allows an
objective, quantitative, and, therefore, measurable account of the child’s
physiological abilities (Arvedson, 2008;
Thach, 2007). Instrumental assessment
approaches reported in the literature
for swallowing in children include videofluoroscopy, endoscopy, high-resolution impedance manometry (HRIM),
and ultrasonography (Dharmarathna
et al., 2018). HRIM was found to have
received the greatest research attention in a recent systematic review with
40% of all published papers reporting
on HRIM (Dharmarathna et al., 2020a).
HRIM offers a valid measure of pharyngeal and esophageal pressures across
time during swallowing. Esophageal
manometry has traditionally been used
clinically for children with achalasia,
for example. Pharyngeal manometry is
newer and is being explored in research
to better understand feeding physiology and development in infants but is
not being widely used clinically, as yet.
Videofluoroscopy is still by far the
most commonly available instrumental tool (Figure 14–2). The challenges
to the clinical team, like many instrumental assessments, include limiting
distress and ensuring the assessment
is a true representation of the child. It
is important to ask, is the child acutely
unwell at the time of the study and is
this their usual feeding position/routine? Optimizing the study is critical
to ensure the ionizing radiation is justified. Although protocols and objective
Figure 14–2. Two-month-old infant bottle
feeding.
measuring approaches (such as the
dynamic swallow study described in
Chapters 6–8) have been normed and
validated in adults, until recently, they
have not been investigated in pediatrics (Gosa et al., 2015; Henderson et al.,
2016). In the past few years, there has
been a surge in publications supporting clinicians to optimize their videofluoroscopy protocols and reporting.
Miles and colleagues provide a comprehensive protocol for quantitative
analysis of liquid swallowing offering
video demonstrations and instructions on how to measure and where
to purchase measuring tools (Miles et
al., 2021). This was based on a number
of validation and reliability studies by
the University of Auckland Swallowing
Research Laboratory (Dharmarathna
et al., 2020b, 2021a, 2021b; Miles et al.,
2022). Early development and validation of a novel infant version of the
adult tool MBSImP
— the BaByVFSSImP
has also been published (Martin-Harris
et al., 2020). This will offer a structured
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