About one in four children admitted to hospital has some type of growth or feeding problem, which can result from underlying conditions including gastro-intestinal and muscular disorders, respiratory illness, or cleft lip and palate. Without treatment these feeding disorders can have lasting effects on a child’s development.
Children with feeding and swallowing problems have a wide variety of symptoms. In very young children these might include irritability and arching the body during feeding, difficulty breastfeeding, refusing food or liquid, difficulty chewing or gagging during meals. Children may also have difficulty coordinating breathing with eating and drinking, regularly spit food back up, suffer from frequent respiratory infections, or have slow weight gain or growth.
So where should parents start in trying to treat feeding difficulties? Seeing a Speech and Language Therapist (SALT) is a good first step; they will analyse the child’s maximum eating and drinking potential, and diagnose whether or not feeding problems are down to a ‘swallow disorder’. The SALT will do a case history, which involves keeping a food diary, taking body measurements and recording symptoms. This will show the child’s eating and drinking skills, swallowing and feeding efficiency, and general behaviour before, during and after meals. It will also give a good picture of social interaction and communication skills.
Following the SALT’s initial investigation, an appointment with a paediatrician might be required to exclude any underlying organic cause that might lead to feeding difficulty such as gastroesophageal reflux disease (caused by stomach acid coming up from the stomach into the oesophagus). Children with feeding difficulties with an underlying organic cause can be very challenging at meal times, and parents often raise the following problems:-
Not showing clear signs of hunger. Children with gastroesophageal reflux disease often ‘graze feed’ or fill up on milk or juice due to their difficulty in eating solid foods, and tend to take a long time to feed. This means that the gaps between meals are too short to create hunger.
Gagging or spitting of textured, chewable foods. Some children struggle to progress from liquids to solids, and can be intolerant of mixed textures and chewable solids as these make them gag or vomit. Learning to bite and chew efficiently is influenced by the sensory properties of the food and its placement in the mouth. Difficulty tolerating textures often results from food making the child feel unwell or the texture being too advanced for them. They subsequently try to avoid new tastes and textures.
Refusal to eat or drink, tantrums during meals. Children with longstanding feeding difficulties due to an underlying organic cause often associate eating or drinking with pain or discomfort. Anticipation of meal times can cause real distress, and the inability to feed their child properly can have a real impact on parents who can feel like ‘failures’ as a result.
Once it is clear if the problem is down to a swallow disorder or an underlying organic cause, the SALT can adapt routines to allow for more time between feeds, suggest feeding utensils and textures which will be tolerated by the child, liaise with a specialist dietician to supplement the child’s diet and address behavioural difficulties during meal times. The SALT will also support parents by setting realistic goals to reach the child’s full feeding potential.
There are four key questions to ask if you are worried about your child’s eating and wondering if you need to see a SALT for a clinical feeding and swallowing assessment:-
1. How long do meal times usually take? If more than about 30 minutes on a regular basis there may well be a problem. Prolonged feeding times can be a clear sign that something needs to be addressed.
2. Are meal times stressful? It is very common for parents to state that they “just dread mealtimes” because feeding their child is so difficult.
3. Does your child show any signs of respiratory stress? These may include rapid breathing, gurgly voice quality, nasal congestion that increases as the meal progresses, or panting by a baby when breast feeding.
4. Has your child not gained weight in the past 2 to 3 months? Steady weight gain is particularly important in the first 2 years of life for brain development as well as overall growth. A lack of weight gain in a young child is like weight loss in an older child or adult.
Analou Louw is a Paediatric Speech and Language Therapist at Bupa Cromwell Hospital.