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Pediatric Feeding Problems: When You Need an Expert and How to Make Eating Fun

Posted on Apr 20, 2018

Speech-Language Pathologist Marybeth A. Smith, M.S. CCC-SLP

Eating should be a happy time for kids and families, but sometimes there are obstacles or underlying medical issues that make it difficult to enjoy. At Johns Hopkins All Children’s Hospital, there is a team of speech pathologists who are experts in identifying a feeding problem and implementing a course of action to correct it. This includes Speech-Language Pathologist Marybeth A. Smith, M.S. CCC-SLP, who is passionate about her career in helping children and their families improve feeding. She has been at it for 28 years.

“Feeding issues can be due to a number of underlying issues such gastrointestinal issues with reflux or constipation, allergies, muscle weakness, sensory processing, Autism or genetic and neurological issues,” Smith says. “We are seeing an increase of patients with gagging issues, which can be due to a variety of underlying reasons–delayed skills that make managing textured foods more difficult, decreased experience, underlying sensory or medical issues (such as reflux), early negative or uncomfortable experiences around the mouth that lead to hypersensitivity, just to name a few.”

Staying on track—stages of feeding

  • Newborn to one year: Recommended liquids are breast milk or infant formula.
  • 4-6 months (good head and neck control): Purees such as rice cereal and pureed/commercial baby food may be incorporated
  • 6-9 months (begins to sit independently): Dissolvables—child begins to gum and swallow dissolvable crackers 
  • 8-11 months (sits alone easily): Child progresses to biting and chewing crackers and cereal, and soft table foods such as cooked fruits and vegetables
  • 12 months (can feed themselves, pick up table food): Prefers finger foods
  • 1-3 years (child is able to eat table food): They eat a wide variety of textures and flavors of foods from all major food groups 

Common feeding problems and the solutions

Problem: In infants, coughing or choking on the bottle or during breastfeeding
Solution: Selecting the right technique/position or bottle/nipple the infant needs in order to drink safely without coughing or choking. Slowing the flow rate down is often key, but can be referred to a swallow study if needed.

Problem: Aspiration (liquid goes down the wrong way) with toddlers and children
Solution: A swallow study is needed to determine if there is actual aspiration and if so, what techniques are effective in managing it.

Problem: Gagging on smell, taste or textures–this can be sensory-related or due to gastrointestinal issues.
Solution: Following or in cooperation with medical management, doing therapy focused on chewing skills and desensitizing child to increase variety of textures and flavors eaten.

Problem: Oral motor weakness or delayed skills for age, such as difficulty chewing table food or moving the tongue side to side to be able to bite, chew and swallow.
Solution: Strengthening and oral motor exercises help children improve these skills.

Problem: Difficulty transitioning to age appropriate foods
Solution: Working with the pediatrician and gastrointestinal physician to determine any underlying medical issues, then using therapy techniques to gradually and systematically expand variety of foods eaten.

Problem: Difficulty gaining weight or getting off a gastrostomy tube.
Solution: Collaborating with the pediatrician, gastrointestinal physician and nutritionist to determine the caloric and nutritional needs and applying feeding techniques to increase overall intake and high-calorie foods.

How can we as parents foster a happy and healthy feeding time?

  • Keep feeding time happy, fun and positive. Avoid meals lasting an hour or more, force feeding or negative reactions to food.
  • Schedule is important. Try to have three meals, two small snacks at the same time each day. Avoid constant snacking.
  • Use a slow, calm gradual approach. Give your child small bites and choices. Start with what they are willing and able to do successfully and gradually introduce changes to expand.
  • If your child experiences gagging or choking on food or liquid, problems gaining weight or any feeding difficulties, talk to your pediatrician about scheduling your child for a feeding evaluation with a speech therapist.


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