Feeding & Swallowing Problems in Children

Overview

Feeding is important to self-care and social interactions as well as for growth and nutrition. In the primary care setting, feeding problems are commonly reported by parents of infants, young children, and older children with neurodevelopmental disorders, although they can occur at any age. Feeding and swallowing problems can involve oral motor skills or sensory aspects of swallowing and feeding, challenging behaviors, environmental factors, quality of life in relation to swallowing or feeding difficulties, and impacts on growth and well-being. Many feeding problems are mild and are handled effectively in the medical home. Severe pediatric feeding disorders can range from dysphagia to avoidant/restrictive eating behaviors, pica, or rumination and may require coordination with one or more specialists to evaluate and treat.
Feeding problems are estimated to occur in 20-45% of typically developing children, whereas 80-90% of children and adults with developmental disorders will have feeding and swallowing problems at some point during life. [Barton: 2018] [Kerzner: 2015] The medical home is the front-line for identification and initial management of feeding and swallowing problems in infants and children with special health care needs. This resource reviews current guidance on assessing pediatric feeding and swallowing problems, describes options for standardized screening tools currently available for use in the pediatric medical home, and provides guidance on how to manage this condition.

Other Names

  • Avoidant Restrictive Food Intake Disorder
  • Feeding Difficulties
  • Pediatric Dysphagia
  • Pica
  • Rumination Disorder

ICD-10 Coding

ICD-10 Diagnosis Codes

  • R63.3, Feeding Difficulties
  • R13.10, Dysphagia, unspecified
  • R62.51, Failure to thrive (child)
  • F50.82, Avoidant/restrictive food intake disorder
  • F98.21, Rumination disorder of infancy
  • F98.22, Other feeding disorders of infancy and early childhood
  • F98.3, Pica of infancy and childhood
  • P92x, Feeding problems of newborn (add specifier)

ICD-10-CM Codes

  • Z13.21, Encounter for screening for nutritional disorder
  • Z13.39, Encounter for screening examination for other mental health and behavioral disorders

Clinical Assessment of Feeding & Swallowing Problems

Feeding and swallowing problems may present initially with a history of:
  • Prolonged meal times or breast/bottle feeding • Difficulty advancing textures in the infant’s diet
  • Frequent choking, gagging, coughing, or vomiting during or after feeding
  • Persistent nocturnal feeding after infancy
  • Lack of child starting to feed him or herself (many babies start trying to self-feed at 9 months and use utensils by 18 months)
  • Child sneaking or stealing food or ingesting non-food items
  • Feeding refusal
  • Stressful mealtimes
  • Parents trying to trick or coerce the child into eating more
Primary care clinicians should be aware that feeding problems tend to develop at transition times, such as when babies start taking a bottle, eating solid foods, or feeding themselves. Whenever the parent or caregiver expresses concern about feeding, the clinician should use the history and physical exam to determine if there are red flags.
  • Organic red flags
    • May include wheezing, choking, gagging, frequent respiratory infections, diarrhea, vomiting, pain with feeding, or developmental delays
  • Behavioral red flags
    • May include refusal of new foods or textures, anticipatory gagging, sudden change in eating habits after an event like choking or oral surgery, forceful feeding by the caregiver, parental-child conflict about feeding, or a limited variety of acceptable foods.
  • Faltering growth and nutritional deficiencies
    • May be caused by both organic and behavioral feeding problems.

Screens for Feeding & Swallowing Problems

There are currently no published guidelines for screening for feeding and swallowing problems in low-risk pediatric populations. However, a screening tool may help clinicians detect children at risk for a feeding problem and can also be considered when there are red flags (see above). A feeding screen can also be used as a proxy assessment tool to monitor the child’s feeding problems over time, such as for a child weaning off dependence on a feeding tube. Finally, responses on screens can serve as a discussion point for clinicians and parents. However, a screen should replace an instrumental evaluation, typically a modified barium swallow study, when there is concern for dysphagia.
Numerous pediatric feeding problem screeners are available, but they vary in quality, age ranges, focus on organic vs. behavioral concerns, length, and psychometric properties. Some require background knowledge or training in pediatric feeding and swallowing disorders and are not applicable in most primary care settings.
Below are examples of screens that could be used in the medical home. Non-standardized instruments, such as questionnaires, which can help guide clinicians taking a feeding history for both orally and tube-fed children, are not included. The first 2 screens are freely accessible and were provided by their authors.

Montreal Children's Hospital Feeding Scale (MCH-FS)

A 14-item parent-report using a 7-pt Likert scale examining 4 types of feeding problems: lack of motivation, oral-motor deficits, food selectivity according to texture, and food selectivity according to taste. Includes questions about parental concerns, mealtime behaviors, family strategies, and family reactions to their child’s feeding. (
  • Ages: 6 months to 6 years
  • Languages: English, Dutch, French, Portuguese, Thai
  • Sensitivity = 87% and specificity = 82% using a total score of 45 as the cut-off.
  • Scoring: Normal range = raw score 0-45 [T-score 35-60], mild difficulties = 46-52 [T-score 61-65], moderate 53-58 [T-score 66-70], severe >=59 [T-score >70]. The questions correspond with specific types of problem: oral motor (items 8 and 11), oral sensory (items 7 and 8), appetite (items 3 and 4), maternal concerns about feeding (items 1, 2, and 12), mealtime behaviors (items 6 and 8), parental strategies used (items 5, 9, and 10), and family reactions to their child’s feeding (items 13 and 14).

Screening Tool of Feeding Problems Applied to Children (STEP-CHILD)

A 15-item parent-report using a 3-pt Likert scale, including chewing problems, rapid eating, food refusal, food selectivity, vomiting, and stealing food. Studied in children with feeding problems, autism spectrum disorder, and special needs.
  • Ages: 24 months to 18 years
  • Languages: English
  • Sensitivity/specificity: N/A. Reliability and validity are addressed in the study.
The following screens may be relevant in specific populations:

Behavioral Pediatric Feeding Assessment Scale (BPFAS)

A widely used parent-report with 35 items on a Likert scale that addresses child behaviors, such as feeding refusals, stalling, and refusal of textures, and parents’ perceptions and strategies. Since it takes approximately 15 minutes, it is not optimal for routine screening in primary care. [Allen: 2015] [Jaafar: 2019]
  • Ages: 9 months to 18 years, although original study validated for ages 9 months to 7 years [Jaafar: 2019]
  • Languages: English and a not-yet-published Greek version [Jaafar: 2019]
  • Scoring: Higher scores are more concerning. Contact the authors for more information.
  • Sensitivity/specificity: >75%/>85% in all domains. [Jaafar: 2019] First published in 2001, the BPFAS has been repeatedly shown to have adequate reliability and validity as a measure of mealtime behavior problems in typically developing children, children presenting to a clinic with feeding difficulties, and children with autism spectrum disorder, cystic fibrosis, CHARGE syndrome, children with diabetes, eosinophilic gastrointestinal disorder, and overweight/obesity.
Contact the study authors [Jaafar: 2019] for more information about accessing the BPFAS.

Brief Autism Mealtime Behavior Inventory (BAMBI)

An 18-item parent report using a 5-pt Likert scale focused on mealtime behaviors in children with autism spectrum disorder. [Lukens: 2008]
  • Ages: 3-11 years
  • Languages: English, Brazilian Portuguese
  • Sensitivity/specificity: N/A. Reliability and validity are addressed in the study. [Lukens: 2008]
  • Scoring: No clinically validated cutoff scores, although studies are underway
See Brief Autism Mealtime Behavior Inventory (BAMBI) (Word Document 27 KB) or contact the study authors [Lukens: 2008] for more information.

Pediatric Assessment Scale for Severe Feeding Problems (PASSFP)

A 15-item parent-report using Likert scales, including quality of life, nutrition, behaviors, oral sensory, and oral motor concerns. Designed to assess progression in oral skills for young children requiring prolonged tube feeding. [Crist: 2004]
  • Ages: At least 4 months
  • Languages: English
  • Sensitivity/specificity: N/A. Reliability and validity are addressed in the study. The scale is shown in the study article. Contact the authors for scoring information.
The scale is shown in the study article. Contact the authors [Crist: 2004] for scoring information.

Management of Feeding & Swallowing Problems

A step-wise approach to managing pediatric feeding and swallowing problems is recommended, particularly if red flags are present.

Step 1: Basic feeding guidance

When concerns are low based on objective data like growth patterns, lack of red flags from the history, and lack of suspicion for underlying medical problems, reassurance and routine growth monitoring and follow-up may suffice. The clinician can also provide basic pediatric feeding guidance: [Kerzner: 2015]
  • Avoid distractions during mealtimes (television, cell phones, etc.)
  • Maintain a pleasant neutral attitude throughout meal
  • Feed to encourage appetite
    • Limit meal duration (20–30 min)
    • 4–6 meals/snacks a day with only water in between
  • Serve age-appropriate foods
  • Systematically introduce new foods (up to 8–15 times)
  • Encourage self-feeding
  • Tolerate age-appropriate mess

Step 2: Are severe nutritional deficiencies and/or celiac disease suspected?

If yes, obtain labs, such as a complete blood count (CBC), complete metabolic panel (CMP), erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP), and urine analysis, plus or minus a celiac disease screening panel (see Celiac Disease , Clinical Assessment). Consider inpatient admission for severe derangements and stabilization.

Step 3. Is dysphagia suspected?

If yes, obtain a modified barium swallow study (MBSS). If dysphagia is present on the study, thicken liquids or feeds as recommended. Consider tube feedings if unable to safely swallow.

Step 4: Is GERD suspected?

If yes, consider acid reflux treatment trial or dedicated imaging studies. See Gastroesophageal Reflux Disease for more information.

Step 5: Referrals

While both feeding and eating disorders can share some common ground, such as food avoidance and restriction, the psychology behind feeding and eating disorders is different. Feeding disorders may be behavioral or organic in nature, whereas body dysmorphia, inappropriate coping skills, or need for control underlies many eating disorders. See Screening for Eating Disorders for more information.

Feeding vs. Eating Disorders

While both feeding and eating disorders can share some common ground, such as food avoidance and restriction, the psychology behind feeding and eating disorders is different. Feeding disorders may be behavioral or organic in nature, whereas body dysmorphia, inappropriate coping skills, or need for control underlies many eating disorders. See Screening for Eating Disorders for more information.

Referral Information

Speech - Language Pathologists (see UT providers [71]) or Occupational Therapy (see UT providers [38])
Feeding therapy can be performed by specialists in feeding disorders, most commonly Speech-Language Pathologists or Occupational Therapists with additional training. Feeding therapy can help the child learn to tolerate different foods and promote safe swallowing techniques in children with dysphagia.
Nutrition Assessment Services (see UT providers [8])
Consider referral for concerns about optimizing nutrition or addressing specialized diets.
Behavioral Therapies (see UT providers [29])
For difficult-to-manage behaviors affecting feeding, consult a Behavioral Specialist such as a Pediatric Psychologist. Behavioral therapies related to feeding problems typically include both parent and child and can be helpful when parent-child relationships have been strained by the feeding dynamic. Therapists can help develop a behavior plan to manage feeding behaviors more effectively at home.
Swallow Studies (see UT providers [1]) / Swallow Disorder/Dysphagia Clinics (see UT providers [1])
A modified barium swallow evaluation can be performed in conjunction with Pediatric Radiologist and a Speech-Language Pathologist.
Pediatric Gastroenterology (see UT providers [4])
Can help in assessment and treatment of severe nutritional deficiencies, dysphagia, gastroesophageal reflux, or other medical or anatomical problems related to digestive disorders.
Pediatric Psychiatry > … (see UT providers [88])
Consider referral for difficult-to-manage behavioral problems, diagnosis, and management of comorbid psychiatric conditions or consultation on pharmacological management.

Resources

Information & Support

For Professionals

Pediatric Dysphagia (ASHA)
Information about feeding and swallowing disorders that includes assessment and treatment; American Speech-Language-Hearing Association.

Eating Disorders: A Guide to Medical Care (PDF Document 364 KB)
A 24-page resource developed to promote recognition and prevention of medical morbidity and mortality associated with eating disorders, using current research and best practices. 2016/3rd Edition; Academy for Eating Disorders’ Medical Care Standards Committee.

For Parents and Patients

Infant & Toddler Forum
Evidence-based advice and simple, practical resources about nutrition and development during the early years of life. Supports families to make healthier nutritional choices and promotes good eating habits in early life for a healthy future for generations of children.

Feeding and Swallowing Disorders in Children (ASHA)
Information for families about identification and management of swallowing and feeding problems in children.

Practice Guidelines

Lock J, La Via MC.
Practice parameter for the assessment and treatment of children and adolescents with eating disorders.
J Am Acad Child Adolesc Psychiatry. 2015;54(5):412-25. PubMed abstract
This practice parameter from the American Academy of Child and Adolescent Psychiatry reviews evidence-based practices for the evaluation and treatment of eating disorders in children and adolescents.

Rosen DS.
Identification and management of eating disorders in children and adolescents.
Pediatrics. 2010;126(6):1240-53. PubMed abstract
This AAP clinical report includes a discussion of diagnostic criteria and outlines the initial evaluation, treatment including pharmacotherapy, and monitoring of the patient with disordered eating. Reaffirmed Feb 2018

Patient Education

Eating Disorders: About More Than Food (NIMH)
Patient education about eating disorders that can be printed as a PDF; National Institute of Mental Health.

Feeding & Nutrition Factsheets for Health and Childcare Professionals (Nutricia)
Free, downloadable factsheets with evidence-based information and best-practice guidance for the feeding and nutritional needs of children 1-3 years old; Infant & Toddler Forum.

Guidance for Parents: Developmental Stages in Infant & Toddler Feeding (Nutricia) (PDF Document 330 KB)
A 12-page, printable handout with evidence-based descriptions of the developmental stages for food and feeding in infants and young children. Includes feeding-related skills; taste, texture, and food preferences; and appetite regulation; Infant & Toddler Forum.

Tools

Dietary Reference Intake Calculator for Healthcare Professionals (USDA)
Calculates daily nutrient recommendations based established by the Health and Medicine Division of the National Academies of Sciences, Engineering and Medicine. Represents the current scientific knowledge; however, individual requirements may be higher or lower than recommendations. Entering height, weight, age, and activity level generates BMI, estimated daily calorie needs, and recommended intakes of macronutrients, vitamins, and minerals based on DRI data. For use with ages 3 and older; US Dept. of Agriculture.

Eating Disorders Screening Tool (NEDA)
Online, self-reported questionnaire for those 13 years and older with approximately 20 questions, taking <5 minutes to complete. Upon completion, the site indicates level of risk and offers next steps; National Eating Disorders Association.

Montreal Children's Hospital Feeding Scale (MCH-FS) (PDF Document 307 KB)
14-item parent report tool examining 4 types of feeding problems: lack of motivation, oral-motor deficits, food selectivity according to texture, and food selectivity according to taste. For use with ages 6 months to 6 years old.

Screening Tool of Feeding Problems Applied to Children (STEP-CHILD) (Word Document 13 KB)
15-question, 1-page screen for feeding difficulties; includes frequency and severity scales.

Screening of Feeding Problems for children (STEP-CHILD): Child and Parent (PDF Document 190 KB)
A 2011 article describing the development of a screening tool to assess feeding problems in children with special health care needs.

Services for Patients & Families in Utah (UT)

For services not listed above, browse our Services categories or search our database.

* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.

Helpful Articles

Harrington BC, Jimerson M, Haxton C, Jimerson DC.
Initial evaluation, diagnosis, and treatment of anorexia nervosa and bulimia nervosa.
Am Fam Physician. 2015;91(1):46-52. PubMed abstract
Recommendations for primary care clinicians on anorexia and bulimia, based on DSM-5 diagnostic criteria. Includes information relevant for adolescents and adults.

Kerzner B, Milano K, MacLean WC Jr, Berall G, Stuart S, Chatoor I.
A practical approach to classifying and managing feeding difficulties.
Pediatrics. 2015;135(2):344-53. PubMed abstract
The objective of this AAP State of the Art Review is to allow the physician to understand the wide variety of feeding-related conditions and to provide information about who and where to refer to specialists in the field.

Herpertz-Dahlmann B.
Adolescent eating disorders: update on definitions, symptomatology, epidemiology, and comorbidity.
Child Adolesc Psychiatr Clin N Am. 2015;24(1):177-96. PubMed abstract
This article aims to convey basic knowledge on these frequent and disabling disorders, and to review new developments in classification issues resulting from the transition to DSM-5.

Brigham KS, Manzo LD, Eddy KT, Thomas JJ.
Evaluation and Treatment of Avoidant/Restrictive Food Intake Disorder (ARFID) in Adolescents.
Curr Pediatr Rep. 2018;6(2):107-113. PubMed abstract / Full Text
Information for pediatricians should be aware of the diagnostic criteria and management of adolescent patients with ARFID.

Heckathorn DE, Speyer R, Taylor J, Cordier R.
Systematic Review: Non-Instrumental Swallowing and Feeding Assessments in Pediatrics.
Dysphagia. 2016;31(1):1-23. PubMed abstract
A study to identify and report on non-instrumental assessments available to clinicians for pediatric swallowing and/or feeding function in order to support clinical decision making.

Authors & Reviewers

Initial publication: February 2021; last update/revision: February 2021
Current Authors and Reviewers:
Author: Jennifer Goldman-Luthy, MD, MRP, FAAP

Page Bibliography

Allen SL, Smith IM, Duku E, Vaillancourt T, Szatmari P, Bryson S, Fombonne E, Volden J, Waddell C, Zwaigenbaum L, Roberts W, Mirenda P, Bennett T, Elsabbagh M, Georgiades S.
Behavioral Pediatrics Feeding Assessment Scale in Young Children With Autism Spectrum Disorder: Psychometrics and Associations With Child and Parent Variables.
J Pediatr Psychol. 2015;40(6):581-90. PubMed abstract / Full Text
This study describes the factor structure and validity of the Behavioral Pediatrics Feeding Assessment Scale (BPFAS; Crist & Napier-Phillips, 2001) when used in preschoolers with autism spectrum disorder (ASD).

Barton C, Bickell M, Fucile S.
Pediatric Oral Motor Feeding Assessments: A Systematic Review.
Phys Occup Ther Pediatr. 2018;38(2):190-209. PubMed abstract
This review describes the clinical properties and psychometric soundness of 12 pediatric oral motor feeding assessments.

Crist W, Dobbelsteyn C, Brousseau AM, Napier-Phillips A.
Pediatric assessment scale for severe feeding problems: validity and reliability of a new scale for tube-fed children.
Nutr Clin Pract. 2004;19(4):403-8. PubMed abstract
This study reports data on the validity and reliability of a new parent report measure, the Pediatric Assessment Scale for Severe Feeding Problems, designed to assess progress in the development of oral eating skills for children who need prolonged tube feeding.

Jaafar NH, Othman A, Majid NA, Harith S, Zabidi-Hussin Z.
Parent-report instruments for assessing feeding difficulties in children with neurological impairments: a systematic review.
Dev Med Child Neurol. 2019;61(2):135-144. PubMed abstract
This study aimed to review the psychometric properties and clinical application of parent-report instruments that assess feeding difficulties in children with neurological impairments.

Kerzner B, Milano K, MacLean WC Jr, Berall G, Stuart S, Chatoor I.
A practical approach to classifying and managing feeding difficulties.
Pediatrics. 2015;135(2):344-53. PubMed abstract
The objective of this AAP State of the Art Review is to allow the physician to understand the wide variety of feeding-related conditions and to provide information about who and where to refer to specialists in the field.

Lukens CT, Linscheid TR.
Development and validation of an inventory to assess mealtime behavior problems in children with autism.
J Autism Dev Disord. 2008;38(2):342-52. PubMed abstract
Validation study of the standardized instrument, the Brief Autism Mealtime Behavior Inventory (BAMBI), designed to measure mealtime behavior problems observed in children with autism. Images of the inventory can be found in the article.