1. Amirault, Lauren M. OTR/L

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Of all the activities of daily living, none is more life-sustaining than eating. A child's ability to eat is critical to her health and wellness, and the daily routines surrounding feeding and eating play an integral role in emotional development, social interaction, and cultural understanding.

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By using a four-part approach to assessment, occupational therapists (OTs) can identify feeding difficulties promptly so children can receive appropriate treatment that leads to the best possible outcomes.


What is a feeding disorder?

A diagnosis of "feeding disorder" is given when an infant or child is unable to consume adequate or age-appropriate food or liquid to support growth and development. Feeding disorders are especially prevalent in children with prematurity, cerebral palsy, Down syndrome, autism, and gastrointestinal disorders.


Four parts of assessment

A feeding disorder is often the result of multiple underlying medical, sensorimotor, and behavioral factors, making the assessment process complex. One way to approach assessment is to incorporate four parts: an interview with the caregiver, a mealtime observation, additional clinical observations, and referrals to other medical professionals when needed.


Caregiver interview

Gather information from the parent, caregiver, or referral source to determine the primary concerns. Ask open-ended questions to elicit information about the child's current feeding patterns and routines over the course of a typical day.


* What types of foods does the child eat, and how much food and liquid is typically consumed?


* How long and how frequent are meals and snacks?


* What types of utensils, bottles, nipples, or cups are used during feeding?


* How is the child positioned at mealtimes?


* What strategies have been used to encourage the child to eat (for example, distraction, withholding preferred foods, rewarding the child with toys), and how successful have these strategies been?


* Does the child eat independently, or is she fed by caregivers?


* How frequently does the child experience coughing, gagging, or vomiting?



In addition to the child's current status, explore the child's medical and feeding history. (See Questions to ask about a child's medical and feeding history.)


Questions to ask about a child's medical and feeding history


* When did the child's feeding problems begin?


* Is there a history of vomiting, gastroesophageal reflux, food allergies, or constipation?


* Has the child ever taken medication for gastrointestinal problems?


* Has the child seen other physicians, nutritionists, or therapists for this problem? What recommendations were provided, and how successful were they?


* Has the child had any diagnostic tests, surgeries, or hospitalizations?


* Has the child ever required nonoral feeding by a nasogastric tube or gastrostomy?


* At what age was the child first introduced to solid foods? How did the child respond to these new foods?


Mealtime observation

The second part of assessment is the direct observation of a meal or snack session conducted by the parent or caregiver. Whenever possible, observe the meal in the child's natural environment. When this isn't possible, encourage the caregiver to use typical foods, equipment, positions, and routines at a time of day when food is usually offered to the child.


During this stage, observe specific feeding components, including positioning, oral sensorimotor function, swallowing speed and coordination, caregiver-child interaction patterns, and food or liquid presentation methods.


* Does the child indicate any signs of hunger?


* What nonverbal or verbal cues are used during the meal session? Does the child open her mouth in anticipation of the spoon, bottle, or cup?


* Are the lips or teeth used to remove the food bolus from the spoon?


* How quickly is the child fed?


* Does the child swallow the food, spit it out, or hold it in her mouth for prolonged periods of time?


* If textured foods are offered, is the child able to mash or chew them before swallowing?


* Are there any clinical signs of aspiration, such as coughing, choking, or raspy breath or vocal sounds?



At the end of the meal observation, ask the caregiver if the child's performance and behaviors were representative of the typical routine.


Additional clinical observations

You can observe additional underlying factors that may be supporting or limiting oral feeding. During general observations, evaluate postural muscle tone, head control, and neuromuscular status. Consider the child's overall cognitive, behavioral, and developmental skills outside of meals.


You can also assess oral sensorimotor skills outside of mealtimes:


* Does the child drool or have an open-mouth posture at rest?


* Does the child explore nonfood items orally or use a pacifier?


* Does the child allow caregivers to brush her teeth?


* Does the child exhibit a hypersensitive gag reflex outside of nutritive feeding activities?


* Are there any structural abnormalities, such as enlarged tonsils or a shortened lingual frenulum?


* Is there evidence of abnormal oral movement patterns, such as tongue thrusting, tongue retraction, or a tonic bite reflex?


* Do these oral movement patterns change when the child's positioning is adapted?




A child's inability to meet her basic nutrition and hydration needs may lead to significant health and developmental consequences. It's important to consider the child's current nutritional and medical needs, and make referrals to physicians or nutritionists as needed. Further, if the child is demonstrating signs of aspiration with food or liquid, a videofluoroscopic swallow study may be indicated to evaluate the safety of oral feeding.


Comprehensive assessment

A comprehensive feeding assessment can give children an edge in early identification and management of feeding disorders. Use a four-part approach-caregiver interview, mealtime observation, other observations, and medical referrals-to provide children with the help they deserve.