Children's Hospital Colorado

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.

Age

Skill

Texture

Volume

Positioning

0 to 4 months

Infant brings one or both hands to the bottle or to mouth while being held

Liquid

Breastfeeding:

  • 1 month: 10-12 feedings per 24 hours
  • 2-3 months: 8-10 feedings per 24 hours

Formula/expressed breast milk:

  • 1 month: 16-24 ounces
  • 1-2 months: 22-28 ounces
  • 2-3 months: 24-32 ounces

Fully supported head, neck and body; slightly reclined

Caregiver present and providing support

Avoid bottle propping with pillow

4-6 months

Introduce spoon feeding/fed by caregiver

Cereal, smooth purees (similar to stage one baby foods)

Breastfeeding:

  • 7-9 feedings in 24 hours

Formula/expressed breast milk:

  • 4-6 feedings in 24 hours
  • 28-32 ounces
  • Iron-fortified infant cereal by spoon at 6 months of age
  • 1-2 tablespoons of single grain cereal mixed with breast milk or infant formula 1-2 times per day

Primary nutrition from breast milk or formula

Sitting with caregiver support or supported in a highchair

6-8 months

Opens mouth in anticipation of food

Cereal, smooth purees, variety of pureed foods similar to stage two baby foods

Breastfeeding: 

  • 4-6 feedings in 24 hours

Formula/expressed breast milk:

  • 3-5 feedings; 24-32 ounces in 24 hours

Solids:

  • Grains: 2-4 tablespoons, twice per day
  • Vegetables: 2 tablespoons, twice per day
  • Fruits: 2 tablespoons, twice per day
  • Proteins: 1-2 tablespoons, twice per day
  • Water: Up to 2-4 ounces per day   

Primary nutrition from breast milk or formula

Sitting in highchair with tray and foot support

8-10 months

Infant holds and bangs spoon; can bring small pieces of food to mouth with fisted grasp

Cereal, smooth purees, variety of pureed foods similar to stage two baby foods, dissolvable solids, very soft solids

Breastfeeding:

  • 4 or more feedings in 24 hours

Formula/expressed breast milk:

  • 3-4 feedings; 24-30 ounces

Solids:

  • Grains: 2-3 tablespoons per day
  • Vegetables: 3-4 tablespoons, twice per day
  • Fruits: 3-4 tablespoons, twice per day
  • Proteins: 2-3 tablespoons, twice per day
  • Water: 2-4 ounces, twice per day

Primary nutrition from breast milk or formula

Sitting in highchair with tray and foot support

10-12 months

Can bring food to mouth with finger grasp; reaches for spoon; introduce open, sipper and/ or cup for practice

 

Pureed foods, dissolvable solids, very soft solids

Breastfeeding:

  • 3 or more feedings in 24 hours

Formula/expressed breast milk:

  • 3-4 feedings; 24-30 ounces

Solids:

  • Grains: 2-3 tablespoons per day
  • Vegetables: 1/4 cup, twice per day
  • Fruits: 1/4 cup, twice per day
  • Proteins: 1/4 cup or 1 ounce, twice per day
  • Water: 2-4 ounces, twice per day

Primary nutrition from breast milk or formula

Sitting in highchair with tray with foot support

12-14 months

Beginning self-feeding with a spoon; gains skill with an open, sipper and/ or cup with straw

Pureed foods, dissolvable solids, soft solids

Offer all foods below three times a day, and choose two of the foods below during snack times:

  • 4 ounces of milk; no more than 24 ounces of milk per day
  • 1/4 cup fruit
  • 1/4 cup vegetable
  • 1/4 slice/piece or 1/4 cup of a grain
  • 1 ounce of protein or 4 ounces of a dairy food

Sitting in highchair with tray with foot support, or in highchair without tray at the table with foot support

15-18 months

Child scoops food and brings spoon to mouth with some loss; continues skill development with cup drinking (open, sipper and/or cup with straw)

Pureed foods, dissolvable solids, soft solids, some solids

Offer all foods below three times a day, and choose two of the foods below during snack times:

  • 4 ounces of milk; no more than 24 ounces of milk per day
  • 1/4 cup fruit
  • 1/4 cup vegetable
  • 1/4 slice/piece or 1/4 cup of a grain
  • 1 ounce of protein or 4 ounces of a dairy food

Sitting in booster or highchair at the table with foot support

18-24 months

Child uses a spoon and cup independently

Pureed foods, dissolvable solids, soft solids, solids

Offer all foods below three times a day, and choose two of the foods below during snack times:

  • 3-4 ounces of milk; no more than 24 ounces of milk per day
  • 1/4 - 1/2 cup fruit
  • 1/4 - 1/2 cup vegetable
  • 1/2 slice/piece or 1/2 cup of a grain
  • 1 ounce of protein or 4 ounces of a dairy food

Sitting in booster chair at the table

2-2.5 years

Child brings spoon to mouth, has completed transition from bottle/breast to sippy, straw and/or open cup

Pureed foods, dissolvable solids, soft solids, solids

Offer all the foods below three times a day, and choose two of the foods below during snack times:

  • 3-4 ounces of milk; no more than 24 ounces of milk per day
  • 1/4 - 1/2 cup fruit
  • 1/4 - 1/2 cup vegetable
  • 1/2 slice/piece or 1/2 cup of a grain
  • 1 ounce of protein or 4 ounces of a dairy food

Sitting in a child size chair or a booster chair at the table

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.

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