Pediatric Feeding Development

Written by Laura Pickler, MD, MPH

Feeding, eating and swallowing are complex processes, with multiple underlying physiological, sensory, motor, behavioral and environmental influences. Studies suggest that feeding difficulties are evident in 25% of all children, and in 70 to 80% of children with developmental disabilities or chronic medical challenges. Aside from consuming adequate nutrition for growth and development, normal feeding and eating are also part of social, emotional and cultural maturation.   

Feeding, eating and swallowing difficulties are common, and patients often first come to their family physician with concerns. A feeding problem can be present even when a child is growing normally. Teasing out the underlying cause can be challenging.

It helps to first understand how normal feeding develops in infancy and early childhood. Feeding involves more than just eating and includes coordination of six physiological and developmental systems:

1. Physiologic stability: neurological development, cardiopulmonary and the GI system
2. Motor skills: oral motor, gross motor, fine motor, postural stability and movement
3. Communication: expression, understanding and social language skills
4. Appropriate nutrition: oral, tube or modified diet
5. Social interaction: social emotional and cognitive/learned behaviors
6. Sensory processing development: toleration of a variety of sensory experiences (tactile, auditory, visual, olfactory, vestibular and proprioceptive)

Children can learn to eat successfully when they have normal anatomy, well-coordinated muscle activity, appropriate sensory processing development, a supportive and predictable eating environment and positive early feeding experiences. Differences in one or more of these areas can lead to feeding difficulties. 

As with other developmental skills, feeding is a process that children learn over time in conjunction with other developmental skills. The following chart outlines the expected skills necessary for successful eating as a child grows. Feeding skills outside of these parameters may be an indication that a child's feeding skills are not progressing as expected.

If primary care providers can identify the underlying causes of a patient's feeding problem, subsequent intervention is more likely to be successful. Many times, a problem is multifactorial and would benefit from a team approach within the context of a child's medical home. Primary care providers can successfully evaluate and manage some patients, but others will require consultation. When would it be time to consider referring a child in your practice for a feeding evaluation versus other intervention? It is important to note that feeding and swallowing evaluations are not the same. Referrals for these evaluations assess different concerns.

The following list provides some indicators of when feeding evaluation and/or intervention may be of benefit:

• Chronic poor growth and compromised nutritional status based on World Health Organization or Centers for Disease Control and Prevention growth charts
• Food refusal, which can include a variety of behaviors such as verbal refusals, throwing foods and distraction and/or avoidance behaviors during mealtime
• Decreased variety of oral intake, which can include refusal of particular food groups and/or age-appropriate food textures
• Decreased volume of oral intake; a child may not be taking enough food by mouth to meet their nutritional and hydration needs
• Transition from tube feeding to oral feeding
• Prolonged feeding time
• Difficulty transitioning to developmentally appropriate solid foods – from liquids to purees, or from purees to table foods
• Persistent gagging, vomiting or choking while eating
• Sensory processing difficulties
• Oral-motor delays or impairments, which can be caused by structural compromise to the oral-facial anatomy or skills may be delayed for other reasons
• A history of gastroesophageal reflux, constipation or other gastrointestinal problems leading to discomfort with feeding
• Medical conditions including but not limited to allergies, respiratory health, neurological factors, sensory factors, premature birth and genetic/metabolic conditions

If a child in your care demonstrates any of the following concerns, an evaluation of swallow function may be indicated.

• Coughing and/or choking while drinking liquids
• Concerns about a child's overall pulmonary health (chronic oxygen requirement or frequent lower respiratory illnesses)
• Neurological or medical condition that may suggest swallowing dysfunction
• Resistance to drinking liquids
• Persistent concerns about growth and weight gain in light of above concerns

If you are interested in further resources for learning about feeding and swallowing issues in pediatric patients, Children's Hospital Colorado's Feeding and Swallowing Program is available to partner with your practice for consults and referrals.

For additional information or questions about feeding and swallowing concerns, call our Program directly at 720-777-6168 or through OneCall at 800-525-4871. You can also email Dr. Laura Pickler or call our dedicated phone line for family physicians at 720-777-3980.