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SWALLOWING DISORDERS IN INFANTS AND CHILDREN

By: Nancy Swigert, MA, CCC-SLP, BCS-S

INFANTS AND BOTTLE/BREAST FEEDINGbaby girl drinking water

Infants gain all their nutrition through breast or bottle feeding until they are at least six months of age. The ability to suck successfully from breast or bottle requires the infant to coordinate three actions: suck-swallow-breathe.   Suck is accomplished with slightly different motions on the breast compared to the bottle, but essentially the lips must close on the nipple and the tongue moves in and out in a suckle motion and presses the nipple against the roof of the mouth, creating pressure on the nipple. As the jaw moves down, it helps create suction to pull the liquid into the mouth. The infant then has to swallow the liquid, and the infant must stop breathing during each swallow and then breathe after swallowing. The suck-swallow-breathe sequence then starts again. Many things can interfere with this sophisticated system for swallowing. Here are some examples of possible causes of difficulty with feeding in infants. Many of these problems can continue to affect the child’s ability to eat and swallow as they grow.

Prematurity – Premature infants as young as 32 weeks post gestation show some emerging skills in sucking and swallowing, but generally are not ready for full oral feeding until between 34 and 37 weeks post gestation. It takes those extra weeks for the infant’s neurological system to develop so it can support the coordination needed. Difficulty with suck-swallow can persist even after that age.

Lip or tongue “tie”– If an infant immediately has trouble with sucking, in the absence of any obvious medical or developmental problems, the infant may be presenting with restricted “frenum” of the lips or tongue. For infants who are breast fed, the mother may experience unusual nipple soreness. The frenum is the little piece of tissue that connects the top and bottom lip to the gum and the tongue to the floor of the mouth. If these are too tight, then the infant can’t get a good latch on the nipple or can’t adequately move the tongue. This restriction may not be obvious, but a speech-language pathologist who works with infants can help decide if that is the problem. It is then easily corrected with minor surgery.

Cleft lip/palate– Because the lips and palate (roof of the mouth) are essential in helping the infant create a good seal and suck, a cleft of the lip and/or palate can cause difficulty. However, most infants with cleft lip/palate can feed successfully with the right intervention. A speech-language pathologist can help determine if the infant will be able to breast feed and what kind of nipple or feeding system will be needed for successful bottle feeding.

Neurological Conditions– Conditions such as Cerebral Palsy or Down syndrome, and other neurological conditions or syndromes that affect muscle tone, can make it challenging for the infant to get a good seal on the nipple or effectively pull milk from the nipple.

Cardiac problems – Infants with cardiac problems often have a hard time during feeding. They may become fatigued and not be able to finish the feeding. Because infants stop breathing each time they swallow, this can cause a change in heart rate. Some compensations, like frequent breaks during feeding, can help the infant be successful.

INFANTS AND SPOON AND CUP FEEDING

Infants are typically introduced to “solids” like cereals and Stage I baby foods sometime after 4 months of age. Each pediatrician will guide the parents in knowing the right age to begin spoon feeding. The ability to suck soft, runny foods from a spoon requires the infant to develop even more sophisticated oral skills. Initially the infant will use the same in-out suckling motion of the tongue they have been using on the bottle/breast, but by around six months of age they don’t have to move their tongue in and out of the mouth to get the food to the back of the mouth for the swallow. In addition, they get better at using their lips to remove the food from the spoon and help bring the food into the mouth.

Most infants are able to drink from a cup by six months of age. There are advantages and disadvantages to using a spouted cup when introducing liquids. If the child is having trouble with spouted cups, the speech-language pathologist can help determine what kind, if any, the child should use. When drinking from an open top cup the child must be able to sit up, hold their head up and close their jaw and lips on the edge of the cup. They then use their tongue to pull the liquid into the mouth.

CHILDREN EATING SOLID FOODS

Moving to solid foods requires even more coordination of the lips, tongue and jaw to allow the child to bite food, move it to the side teeth for chewing, recollect it on the tongue and move it to the back of the mouth for swallowing.   Toddlers and children may experience feeding and swallowing problems related to some of the medical problems described above. They may also present with feeding/swallowing problems if they are delayed in development of their motor skills. Still other children may present with feeding problems without an obvious cause. Feeding/swallowing problems in children can be classified into several main categories, although many children have problems in more than one category:

Related to motor problems– Children who have trouble with the coordinated movement of lips, tongue, or jaw will likely have trouble with successful eating. They may not be able to handle foods like other children their age.

Physical problems – Children with craniofacial problems like cleft lip/palate or jaw abnormalities will encounter difficulty with feeding. Physical problems might also be in the intestinal tract that prevent the child from digesting food.

Related to sensory problems – Some children have trouble processing the many different sensations related to food: temperature of the food, texture or smell of the food, taste and even color of the food may present a challenge. Children with sensory problems may develop food selectivity or food refusal. Their nutritional intake may be very limited. Not all food selectivity or refusal is related to sensory problems, and any physical problems interfering with safe, successful eating must first be ruled out.

WHAT TO DO IF YOUR INFANT OR CHILD HAS FEEDING/SWALLOWING PROBLEMS

Discuss your concerns with the child’s pediatrician right away. The next step will likely be a referral to a speech-language pathologist with expertise in this area, or perhaps to a multi-disciplinary feeding team. The sooner a feeding/swallowing problem is identified and appropriate treatment begun, the better chance the child has to improve their skills.



13 Comments On “SWALLOWING DISORDERS IN INFANTS AND CHILDREN

  1. Tiffany Reply

    My son is 9 yrs old. Was born with cleft palate and tongue tie… cleft is repaired tongue was clipped but still tied. Dr clipped as much as he could. Why can’t I get my son to suck out of a hard sippy cup or cup period. He will only drink out of the soft stage 2 nuby sippy cups.. he chews on them. He has seen a feeding clinic for a few years and nothing. Also I tried almost every sippy cup and no luck. He will literally go thirsty. Until I give him a soft one. Could he not have the suction to get out of a hard one or perform the right curve of the tongue to get out of a straw.. tried the nosey cup and flow is too fast for him. Is there anyway I could get some advice here.. thanks…

    1. Lucia Ciampa Reply

      My son had a severe posterior tongue tie and experienced similar difficulties with cup drinking. It sounds familiar. I would recommend seeing a specialist in tongue tie to get an evaluation of whether he might benefit from further surgery or if he is best helped by swallowing/sucking therapy. Either way don’t give up on getting the right treatment and support for your child.

  2. Gina Weal Reply

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    For parents, Naso Bib means NO MORE PINNING, NO MORE TAPING! Prior to our invention, parents with infants/children who have nasogastric tubes were taping the balance of tube to their infant or child’s clothing, which can be unattractive and uncomfortable. Naso Bib was created and designed to 1) discourage infants/children from pulling out their tubes, and 2) to hide the extra tubing that can be pulled and cause harm to the child. If the child cannot see the tube, they are more likely not to pull out the tube, which in turn eliminates a major medical and safety concern.

    Naso Bib has concealed pockets on either the right or the left side, just below the shoulder area in front of the bib, with a matching pocket on the back flap. Again, these pockets are used to hide that excess tubing that parent’s are currently tapping or pinning to their children clothing. Our bibs have 2 snaps for adjustability, and fits sizes 3-12 months or 12 months-3-years. The bibs are made out of 100% cotton flannel and are very soft to touch. In addition, it has a nylon layer inside the bib, which makes it water resistant. Naso Bib will work with any type of nasogastric tube, and no matter what side of the bib in which the nasogastric tube is placed, the bib can accommodate the tube.

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  3. Thaisa Sotomayor Reply

    This is good information for parents.

  4. Britni Becker Reply

    My daughter is almost 11 months old and she refuses to eat baby food or any food at all. She also refuses to drink any kind of juice all she will drink is her formula.We’ve been concerned with this issue for several months but her pediatrician kept telling us she was fine. We’ll now she is sending her to a swallow specialist, which is confusing for my husband and I seeing as though she has no problem drinking her formula. I’m really worried about her. Can someone help me understand what the swallow therapist will do?

    1. Ila Handy Reply

      A swallowing specialist would most likely be an SLP (Speech-Language Pathologist, AKA, Speech Therapist), who could help determine if there is a underlying functional cause for your daughters refusal of solid food. It is possible she has aversions which may be sensory in nature, which most SLPs who address feeding issues address. You may also be referred to an Occupational Therapist (OT) who could assess your child for sensory issues which may be contributing to your child’s behaviors. I am a Speech-Language Pathologist who specializes in feeding disorders and I regularly consult with OTs on kiddos if I suspect sensory issues. I hope this helps a little, all my best to you and your little one!

  5. Guneet kaur Reply

    My baby is 20 days old he is unable to take breast feed and even not with bottle. He is on tube feed plz suggest me what to do. [NFOSD moderator note… we have reached out to this person asking if they would like a referral to a pediatric swallowing specialist.]

  6. Nicoletta Fasano Reply

    Nancy, on behalf of the organization I work for, Feeding Matters, we are so pleased to see discussion about this misunderstood and underserved issue. Thank you for writing this piece!

    With over 1,000,000 infants and children nationwide who battle with the fundamentals of feeding, we need more advocates like you and the National Foundation of Swallowing Disorders. Feeding Matters is here to bring pediatric feeding disorders to the forefront so infants and children are identified early, families’ voices are heard, and medical professionals are equipped to deliver collaborative care. To learn more about pediatric feeding disorders or to find help, please visit http://www.feedingmatters.org.

  7. CR Reply

    I am an SLP working with a 10 month old baby. She presents with insufficient nutritional intake and has difficulty feeding from a bottle without significant leakage. She has difficulty retaining liquid or baby food in her mouth. Can you guide me to resources for this problem?

  8. Lak Reply

    My sister’s daughter has swallowing difficulties from birth. She never swallowed and is now on tube feed. She is 1.5 years old. Tests have shown that there is no structural damage in food pipe. Doctors say her muscles are too weak for the swallowing action. Please suggest what to do further.

  9. Neeraj Reply

    Here a baby of 8 days..She is facing a problem of swallowing any type liquid

    1. Member nfosdadmin Reply

      Hi Neeraj, Please email us at info@nfosd.com if you would like a referral to a swallowing specialist in your area. Sincerely, The NFOSD Team

  10. Nicki Reply

    My daughter is 5 last week she choked and now all of a sudden she is afraid to eat anything solid. She will only eat yogurt and pudding. Any information on how to help her not be afraid of food would help.

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