Journal of Pediatric Rehabilitation Medicine: An Interdisciplinary Approach 10 (2017) 95–105 95

DOI 10.3233/PRM-170435
IOS Press

Pediatric feeding and swallowing

rehabilitation: An overview
Lenie van den Engel-Hoeka,∗ , Celia Hardingb , Marjo van Gervena and Helen Cockerillc
a
Donders Centre for Neuroscience, Department of Rehabilitation, Radboud University Medical Center, Nijmegen,
The Netherlands
b
City University, the Royal Free Hospital, London, UK
c
Evelina London Children’s Hospital, Guy’s and St. Thomas’s NHS Foundation Trust, London, UK

Accepted 20 January 2017

Abstract. Children with neurological disabilities frequently have problems with feeding and swallowing. Such problems have
a significant impact on the health and well-being of these children and their families. The primary aims in the rehabilitation
of pediatric feeding and swallowing disorders are focused on supporting growth, nutrition and hydration, the development of
feeding activities, and ensuring safe swallowing with the aim of preventing choking and aspiration pneumonia. Pediatric feeding
and swallowing disorders can be divided into four groups: transient, developmental, chronic or progressive.
This article provides an overview of the available literature about the rehabilitation of feeding and swallowing disorders in infants
and children. Principles of motor control, motor learning and neuroplasticity are discussed for the four groups of children with
feeding and swallowing disorders.

Keywords: Pediatric, rehabilitation, feeding and swallowing, dysphagia

1. Introduction can Speech-Language-Hearing Association documents

have adopted ‘feeding and swallowing disorders’ as the
The act of feeding and swallowing is typically de- more inclusive phrase for dysphagia and delays and/or
scribed in three phases. In the oral phase (suckling dur- disorders in the development of eating and drinking
ing breast feeding, sucking when bottle feeding, eat- skills, which are common in a variety of pediatric pop-
ing with a spoon, drinking from a cup or chewing ulations [2,3]. Feeding and swallowing disorders have
solid food) the bolus is prepared and transported to the a great impact on the health and well-being of chil-
pharynx. In the pharyngeal phase the swallow reflex dren and their families. Dysphagia can also have a
is triggered and the bolus is moved through the phar- negative effect on dietary intake, growth and devel-
ynx. In the esophageal phase the bolus is transported opment [4]. In addition, parents experience stressful
to the stomach. Swallowing is a complex process that child-caregiver interaction, worries about choking and
involves reflexive and voluntary motor control and in- poor growth, and social isolation [5,6].
traoral sensory processing. Together with sensorimotor Feeding and swallowing disorders vary widely in
integration and autonomic regulation it enables the safe terms of presentation, severity and frequency, and the
ingestion of food and liquid [1]. Since 2007 the Ameri- available treatment strategies [7]. As discussed by
Arvedson et al. (2010), the disorders can be divided
into four different groups: transient, developmental,
∗ Corresponding author: Lenie van den Engel-Hoek, Donders Cen-
chronic or progressive [7]. In examples where the skills
tre for Neuroscience, Department of Rehabilitation, Radboud Uni-
have not been acquired within the typical age range,
versity Medical Center, Nijmegen, Geert Grooteplein 10, 6525 GA
Nijmegen, The Netherlands. Tel.: +31 24 3615187; E-mail: Lenie. due to prematurity, neurological conditions or develop-
[email protected]. mental delay, specialized training strategies and more

1874-5393/17/$35.00 c 2017 – IOS Press and the authors. All rights reserved
96 L. van den Engel-Hoek et al. / Pediatric feeding and swallowing rehabilitation

practice may be needed for the child to acquire feed- the use of oral motor exercises in pediatric dysphagia
ing skills [8]. In children with progressive diseases or rehabilitation; and (3) the current evidence related to
trauma, adaptation and compensatory strategies need the treatment of the four main patient groups of feed-
consideration. ing and swallowing disorders. Examples of rehabilita-
The primary aims in the rehabilitation of pediatric tion based on the concepts of motor learning will be
feeding and swallowing disorders are focused on sup- given.
porting nutrition and hydration, adequate growth, on
the development of feeding skills, and ensuring safe
swallowing, as well as the prevention of choking and 2. Motor control and motor learning
aspiration pneumonia. Pediatric swallowing rehabil-
itation must be considered as different from adult Motor control and motor learning are essential com-
swallowing rehabilitation. In children the oropharyn- ponents of the development of feeding and swallow-
geal anatomy is still developing, oral movements ma- ing in children [8]. Motor control is the process of cre-
ture from reflexive to volitional and children learn to ating a sequence of movements for the performance
manage a range of food textures as well as learning of coordinated and skilled actions. This involves in-
to use a variety of different utensils. Infants develop teraction between the central and peripheral nervous
from being totally dependent during feeding to to- systems. The importance of sensory input for accurate
tally self-feeding. In contrast, the swallowing rehabili- motor control and motor learning must be emphasized.
tation in adults depends on a memory for motor com- Food of different consistencies initiate swallowing by
ponents of swallowing (often referred to as an ‘inter- taste, touch, temperature and pressure. Increased sen-
nal model’) [9], whereas in infants and children new sory input can modify motor areas of the cerebral cor-
skills have to be learned. Therefore, the term habili- tex [11]. Stimulation of a greater number of receptive
tation is sometimes used. Habilitation and rehabilita- fields induces a stronger reflex with greater muscle ac-
tion both focus on the act of learning skills. The dif- tivity and force [12]. Ease of movement is possible due
ference between the two is that habilitation focuses on to a steady stream of sensory information while an ac-
learning new skills whereas rehabilitation focuses on tivity is planned, executed and evaluated [9]. In addi-
regaining skills that have been lost. In this overview, tion to using sensory feedback during an activity, the
we will use the term rehabilitation to represent both ha- human nervous system also has the capacity to predict
bilitation and rehabilitation due to the overlap between sensory consequences of motor commands. Shadmehr
transient, developmental, chronic and progressive dis- and colleagues (2010) concluded that human beings
orders of feeding and swallowing. are able to estimate the movement required by predict-
Clinicians who treat children with feeding and swal- ing what should happen, and by receiving information
lowing problems frequently incorporate oral-motor ex- of the sensory system about what did happen, to make
ercises (OME) into their treatment plans. In the light of comparisons [13]. These concepts are significant for
motor learning concepts and principles of task speci- oropharyngeal swallowing. It is suggested that while a
ficity (see next paragraph for description of these bolus is still in the oral cavity, some sensory predic-
terms), controversy exists about the theoretical basis tions about readiness for the pharyngeal swallow are
and effectiveness of these interventions for individu- made, related to bolus size, temperature, and consis-
als with swallowing disorders, particularly in pediatric tency. In infants and children all these activities have
populations [7]. Consequently, there has been a shift to be learned through experience.
towards therapy goals which are based on motor learn- Motor learning and motor adaptation are impor-
ing for feeding and swallowing skills during the meal- tant in the development of new feeding skills. Mo-
time itself [7,8,10]. tor learning is defined as the acquisition of skills or
The aim of this paper is to provide an overview skilled movements as a result of practice. It is a grad-
of the available recent literature about the rehabilita- ual process based on reduction of error and the de-
tion of feeding and swallowing disorders in infants and velopment of successful movements. Sensory informa-
children, and the available evidence on a range of in- tion is used in a feedback and feedforward way to
terventions. The article will include: (1) a description modify motor activity [9]. For example in the acqui-
of the principles of motor control and motor learning sition of chewing, different stages can be identified.
and the role in the development of feeding and swal- Animal studies have shown that tactile receptive fields
lowing; (2) an overview of the available evidence for on the tongue often have reciprocal receptive fields on
 L. van den Engel-Hoek et al. / Pediatric feeding and swallowing rehabilitation 97

Table 1
Important principles of neuroplasticity related to pediatric swallowing rehabilitation (from Robbins et al., 2008; Keim and Jones, 2008; Morgan
2011 [17,18,21])
Principle of neuroplasticity Examples in pediatric feeding and swallowing rehabilitation
Age matters In premature infants and neonates the offering as early as possible of experiences with sucking and
swallowing of little amounts of milk
Specificity Offering smaller amounts of food on a spoon if spoon feeding has to be learned
Use it or lose it Offering small amounts of chewable food if mastication of hard food becomes increasingly difficult
Repetition and intensity matters In normal development infants and children are experiencing a high amount of practicing with feeding
and swallowing. In rehabilitation at least daily repetition of the task is offered
Transference The act of eating chewable food is transferred to other environments (such as school) or with other foods
with similar properties (taste, consistency)

the hard palate [12,14]. The munching and crushing of formed in other circumstances. In general it is accepted
food, seen in the initial stages of eating chewable food, that an early start of intervention (‘age matters’) and
is not only a primitive way of eating, but has the im- task specificity are important [18,21].
portant function of learning the sensory characteristics Although not specific to children with dysphagia,
of solid food, such as consistency and flavor. Gagging, principles of motor learning can provide guidance to
which is often seen when solid food is introduced, can clinicians in selecting appropriate therapeutic strate-
be seen as a warning: this piece is too big to swal- gies when only limited or equivocal research is avail-
low [15]. Using this information infants will act differ- able.
ently with the next bite. Motor learning, with the influ-
ence of sensory information with feedback and feed-
forward, will help them to swallow an increasing range 3. Active and passive oral motor exercises
of food textures effectively.
Neuroimaging studies have demonstrated a strong Oral-motor exercises (OME) are often incorporated
link between motor learning and neuroplasticity [16]. into treatment plans for children with feeding and
Neuroplasticity refers to the ability of the brain to swallowing disorders. There are three main categories
change and to adapt to new conditions. Change and of OME generally used in clinical practice: active ex-
adaptation occur, for example, in response to training, ercises, passive exercises, and sensory approaches.
experience and aging. These changes lead to behav- Active exercises include an active range of move-
ioral changes [17]. Principles of neuroplasticity (such ment (such as sticking out of the tongue) and strength
as ‘age matters’, ‘specificity’, use it or lose it’, ‘repe- training (such as exercises for tongue strengthening).
tition and age matters’, and ‘transference’) and motor These exercises are aimed at increasing strength, en-
learning related to swallowing rehabilitation in adults durance, and power. Sjogreen and colleagues (2010)
are important to consider [17]. Attempts have been used lip strengthening exercises in children with my-
made to translate some of the principles to pediatric otonic dystrophy and found increased lip strength, but
swallowing rehabilitation (Table 1) [18]. The princi- no generalisation to improved functional feeding and
ple of ‘age matters’ refers to the well-recognized idea swallowing [22]. This well designed study underlines
that training influences more readily the younger sys- the necessity to use task specific training in children
tem than the older nervous system. Task-specific train- with feeding and swallowing disorders. The evidence
ing is the repetitive practice of a task that is specific base for the use of OME in isolation, outside a func-
to the intended outcome [8]. The principle of ‘speci- tional setting, is weak. The assumed relation between
ficity’ suggests that a treatment exercise should closely OME and the activity of eating and swallowing is ques-
parallel the desired task [19,20]. ‘Use it or lose it’ is a tionable [10]. It is likely that different sites in the cen-
concept which is important in the treatment of progres- tral nervous system are being activated during nutritive
sive diseases. Although principles such as ‘repetition movements and during volitional motor activities that
matters’ and ‘intensity matters’ are thought to be sig- are often trained with OME [23]. Arvedson and col-
nificant in rehabilitation, it is not known what and how leagues (2010) found in their systematic review, that
much is effective in pediatric feeding and swallowing there is insufficient evidence to determine the effects of
rehabilitation. The ‘transference’ principle highlights OME on the skills of children with oral sensorimotor
the idea that tasks that are learned easily can be per- deficits and swallowing problems [7].
98 L. van den Engel-Hoek et al. / Pediatric feeding and swallowing rehabilitation

Passive exercises may include massage, stroking, sohn manoeuvre have largely been tested in the adult
stretching, and tapping, with little active movement population and not with children. Morgan stated that
from the individual receiving treatment [7,24,25]. their application should be limited to older children
These procedures are applied to provide sensory in- who have adult-like swallowing physiology [18].
put or improve circulation. It has been theorized that In summary, the evidence for the benefits of OME
some of these techniques normalize feeding patterns in pediatric dysphagia rehabilitation is weak. Recent
by reducing abnormal oral reflexes, facilitating normal studies show the theoretical advantages of the use of
muscle tone and normal movements or desensitizing principles of motor learning in pediatric feeding and
the oral region. However, benefits of the passive exer- swallowing rehabilitation. Humbert (2013) showed the
cises have not been reported [26]. The typical stretch combined influence of motor learning and oral sen-
reflexes, which can be seen in skeletal muscles are sory feedback on the cortical representations of oral
lacking in tongue and lip muscles [26,27]. Therefore muscles [9]. SLTs are increasingly incorporating these
it is unlikely that these exercises would improve oral principles in their treatment, underlining the need to
strength or alter muscle tone. perform well designed studies in this field.
Sensory approaches usually consist of the applica-
tion of heat, cold, electrical stimulation, high-
frequency vibration or other activity involving stimu- 4. Pediatric feeding and swallowing disorders in
lation of the skin and muscle tissues. Although com- the four patient groups
mon in the past, many of these techniques are no longer
used. They were based on the idea that vibration or ic- 4.1. Transient feeding and swallowing disorders
ing and brushing would influence muscle activity over
a long period (20–30 minutes) [28]. However, studies Transient feeding and swallowing disorders are fre-
have shown that the effect only lasted for 30–45 sec- quently seen in children who were born prematurely. A
onds [29]. These studies contributed to a change to- significant amount of research has been performed in
wards task specific training and therapy based on mo- the last two decades to describe the feeding and swal-
tor learning in therapy for feeding and swallowing dis- lowing disorders, to investigate possible treatment and
orders by speech language therapists (SLTs) [29]. to assess the outcome of treatment. The prevalence of
Neuromuscular electrical stimulation (NMES) of feeding problems in former premature infants is twice
the anterior neck muscles has been explored in the that of full term infants and the reasons for feeding
treatment of adults who have dysphagia. The hypoth- problems are multifactorial [32]. SLTs are often in-
esis is that the electrical impulses can improve pha- volved in the assessment and management of feeding
ryngeal muscle strength in combination with acceler- in this population.
ated cortical reorganization [30]. Chen and colleagues Keeping in mind the concepts of motor learning
(2016) found in their review that the evidence was and task specificity, knowledge of normal development
insufficient to indicate that neuromuscular electrical of sucking, swallowing and breathing is essential in
stimulation alone was superior to swallow therapy in the management of this patient group. In addition, the
dysphagia after stroke [31]. NMES has been tested in a pharyngo-esophageal motility and airway protection
group of children who had dysphagia with a variety of mechanisms and the overall state of infants have to be
disorders, both congenital and acquired [30]. The au- taken into account.
thors tested NMES treatment of anterior neck muscles, Jadcherla and colleagues (2012) have described
compared to a similar group who received traditional an interesting approach incorporating all these ele-
therapy approaches to remediate dysphagia. Patients ments [32]. The cue-based feeding approach in oral
who received NMES did not show improved swallow feeding therapy, described in this study, refers to in-
function in comparison with patients who received tra- dividualized, developmentally appropriate practice in-
ditional therapeutic interventions. Both groups were stead of the traditionally volume-driven feeding model.
heterogeneous and there is a possibility that there could In the initial phase non-nutritive sucking (on a pacifier)
be subgroups of children that will improve with NMES to stimulate sucking and prepare for nutritive sucking
treatment, especially those with acquired dysphagia. is provided [33]. However, it should be noted that non-
Further studies could perhaps consider this. nutritive sucking does not always enable an infant to
In addition, swallowing manoeuvres, such as the achieve full oral feeding more quickly than those in-
supraglottic swallow, effortful swallow or the Mendel- fants who do not use non-nutritive sucking [34]. Us-
 L. van den Engel-Hoek et al. / Pediatric feeding and swallowing rehabilitation 99

ing non-nutritive sucking is important for helping the 4.2. Developmental feeding and swallowing disorders
infant to achieve the quiet alert state appropriate for
feeding, and it can support parent learning on how to Developmental feeding and swallowing disorders
interpret differing infant states and therefore support are seen in children with developmental delay or with
parent-bonding [34]. After the initial phase, oral feed- genetic syndromes as a result of the complex interac-
ing is introduced in a stepwise manner, at around the tions between anatomical, medical, physiological and
age of 34 weeks gestational age when coordination of behavioural factors [39]. For example, in children with
sucking, swallowing and breathing is neurodevelop- Down’s syndrome a combination of problems might be
mentally possible [35]. The importance of observing the cause of dysphagia. Developmental delay and neu-
the infant before, during and after feeding, is empha- romotor incoordination, in combination with hypoto-
sized by the Early Feeding Scale [36]. This instrument nia, poor tongue control and open mouth posture, of-
ten interfere with the acquisition of effective feeding
supports the observation of the impact of sucking and
skills. The management of these feeding difficulties
swallowing on respiratory rate, heart rhythm and oxy-
is often possible with an appropriate feeding program
gen saturation. It enables the neonatal practitioner to
(matching with the mental and/or developmental stage
observe how the infant’s overall neurological system is
of the child) which consists of three important factors.
maturing in relation to feeding. A feeding program that (1) must be safe, (2) must sup-
From research it is known that premature born in- port optimal growth and nutrition, and (3) must be re-
fants need well-coordinated sucking, swallowing and alistic and based on the development of feeding skills.
breathing to cope with milk intake. However, this Normal developmental acquisition of eating skills
pattern may not have been established when oral in infants is described in terms of milestones [8]. The
feeding is started [37]. Initial feeding attempts at broad milestones are considered to be nippling (breast
32 to 34 weeks are characterized by uncoordinated or bottle), eating from a spoon, drinking from a cup,
suck-swallow-breathe sequences, with some apnoeic and biting and chewing [40]. Weaning is the process
episodes. As the infant develops, the suck-swallow- of expanding the diet of an infant to include food and
breathe cycle becomes more coordinated with longer drinks other than breast milk or formula [41]. Feed-
sequential suck bursts, shorter pauses between sucks, ing in the weaning period is considered not only as
and fewer apnoeic episodes. Finally, breathing ef- the transition from milk to solids, but also the transi-
forts are integrated into an overall suck-swallow-breath tion from sucking to eating with a spoon, and to chew-
rhythm around 36 weeks [35]. The initial series of ap- ing and biting. Furthermore, the interaction between
noeic suckle runs can have a negative influence on caregiver and child is gradually replaced by indepen-
feeding experience because of choking and desatura- dent eating and drinking by the child. The child’s new
tion. In line with the principles of task specific training, skills are gradually improved by experience in combi-
pacing can be used in combination with a low flow teat. nation with the use of different utensils and a variety
Pacing involves the feeder regulating the number of of foods. For example, the first attempts by the child
sucks per burst and the duration of bursts and pauses by to remove the food from the spoon may be uncoordi-
nated, but through trial and error and with repetitions
systematically removing the nipple from the mouth, or
during daily feeding sessions the new skill is acquired
interrupting the seal on the nipple [38]. By using pac-
in 5–7 weeks [15]. In this motor learning process, effi-
ing the neonate is offered early experiences with oral
ciency and independence through daily, functional ex-
feeding (‘age matters’) without negative experiences.
periences and practice are progressively achieved as
Parents are encouraged to feed their child with pac- the skill improves. In children with developmental de-
ing to train safe oral feeding and enhance the relation lay and difficulty with feeding, it will take more time to
with their child. In addition, pharmacological manage- improve this skill in combination with careful rehabil-
ment in case of bronchopulmonary dysplasia or gastro- itation. Thelen (1989) suggests that it is the task, and
esophageal reflux is essential and must be based on not any pre-existing practice of component skills, that
assessment and evidence based guidelines. The over- supports the development of the emerging skill [42].
all goal of treatment is to improve the quality of the She considers both action and sensory perception, as
feeding experience for both the infant and parent rather represented in the target task, important in learning
than, in the first place, focusing on the quantity of food new motor skills. These should not be replaced by sim-
intake [3]. ulated tasks in which component skills are practiced,
100 L. van den Engel-Hoek et al. / Pediatric feeding and swallowing rehabilitation

with assumption that these will combine to achieve the 4.3. Chronic feeding and swallowing disorders
functional skill. Therefore, eating from a spoon has to
be learned, whilst food of an appropriate texture is pre- Infants and children with neurological disorders of-
sented on a spoon. Therapy interventions should pro- ten have dysphagia, based on the insufficient neural
vide practice with gradually increased bolus size, num- coordination of swallowing, alongside other problems
ber of accepted spoons, and promptness in taking the such as hypertonicity or hypotonicity. Cerebral palsy
food [8]. (CP) is the most common form of neurodevelopmental
Problems with chewing are often reported in chil- disability. Prevalences of dysphagia range from 43% to
dren with developmental disabilities and are very com- 99% in children with CP of varying levels of physical
plex, involving the growing oral anatomy, the sensory disability [45,46]. In CP dysphagia is often character-
information which has to be combined with adequate ized by problems in both the volitional oral movements
motor responses, and the experience of new consisten- and the more reflexive pharyngeal phase of swallow-
cies and tastes. The oral anatomy consisting of bones, ing. Moreover, impaired ability to plan and coordinate
muscles, teeth and soft tissues is dynamic over the swallowing with respiration is often present, due to the
course of a child’s development. Changes occur during central nervous system disorder. This lack of coordi-
growth, but are also affected by the activity of chew- nation can result in aspiration (with cough, or silent)
ing. For example, palatal width and height increase ex- with aspiration pneumonia, often being reported [47].
tensively in the first two years, requiring modification With changes in nutritional needs (i.e. related to the re-
of the motor planning during chewing [43]. The de- quirement of increased quantities of food and a broader
velopment of chewing efficiency starts with munching range of consistencies, which might be too difficult to
and crushing and ends in efficient chewing with lateral swallow), growth of the oropharyngeal area in puberty,
movements of the tongue followed by the movement of
increased scoliosis and increasing spasticity, aspira-
the food from the teeth to the pharyngeal area for swal-
tion may become more frequent in older children [47].
lowing [43]. The effect of food consistency on chil-
Arvedson and colleagues (1994) identified that in chil-
dren’s development of chewing has not been explored
dren with CP, aspiration was most prominent for liq-
widely. Both human and animal studies have reported
uid, either alone or with some other texture [48]. In
the effect of food consistency on orofacial develop-
these patients, aspiration does not appear to be an
ment, suggesting that a diet of soft food might nega-
isolated event. It is highly associated with disorders
tively influence bone and muscle growth and therefore
of pharyngeal and esophageal motility. First attempts
reduce chewing competence [44]. This underlines the
necessity of paying attention to the process of mastica- have been made to describe these problems in chil-
tion in children with developmental delay in the early dren by Rommel and her research group [49]. In chil-
stages of life. dren with CP they used the deglutitive flow interval,
To learn the skill of effective chewing, specificity derived from pharyngeal impedance recordings. The
and repetition are the most important components. In- impedance measurements can detect alterations in flow
sufficient mastication is often accompanied by fre- characteristics of pharyngeal swallowing resulting in
quent gagging, because small children try to swallow post swallow residue. This flow interval was clearly al-
pieces that are too large, and inadequately prepared. tered in relation to pathology and may potentially be
A protocol with careful described steps can positively combined with pressure measurement as a measure of
impact on the development of chewing solid foods. dysfunction. It highlights the complexity of dysphagia
This should include chewing skills that are trained by at all stages of swallowing in children with CP.
first placing foods on the preferred side for chewing, It would seem logical that feeding and swallowing
enhancing graded jaw movement and lateral tongue interventions lead to benefits, which are measurable
movements. Food texture is carefully modified, work- and objective. However, the current level of evidence
ing from soft to mixed textures and then later to firm is poor with limited information regarding outcomes.
consistencies. Practicing mastication in different situ- Randomized controlled trials for intervention are diffi-
ations highlights the ‘transference principle’, because cult in this heterogeneous population of patients with
of the influence of the first experiences on the perfor- CP, with ethical concerns about not intervening in chil-
mance of the skill in a variety of environments [8]. dren who have an impaired swallow [47]. Only 5 ran-
During this process, motor control, sensory tolerance domized controlled trials were found in a review of
and sensory capabilities are developing simultaneously 12 electronic databases [50]. Feeding safety and effi-
resulting in the new skill of mastication [8]. ciency were primary outcomes in some studies, height
 L. van den Engel-Hoek et al. / Pediatric feeding and swallowing rehabilitation 101

and weight changes in others. Various interventions are with CP challenge therapists and parents to establish
described in children with CP: (1) oral sensorimotor the optimal positioning for feeding. Hyperextension of
programs and/or muscle strengthening, (2) thickening the neck may hamper laryngeal protection during swal-
liquids, (3) changing postures and (4) the use of motor lowing [55]. It is hypothesized that positioning of the
learning in CP. trunk and head is the most basic and essential treatment
Gisel (1994) completed a study in children with for dysphasic children with CP. Snider et al. (2010)
CP which explored the development of oral motor found in their systematic review that there is only lim-
skills [51]. She compared training of oral motor skills ited evidence (based on a few case series) that posi-
(referred to as oral sensorimotor therapy) in differ- tioning has a positive effect on feeding and swallowing
ent groups of children with CP. Specific skills such in CP children [50]. In a small study with 6 children it
as lip closure for the retention of food, and biting to was shown that with a slightly reclined posture and a
break through a piece of solid food were trained with flexed neck, aspiration decreased both on thin liquids
small food bits, before mealtime. Lip closure, biting and pureed food [55].
and chewing improved after 20 weeks. Although lip The effects of motor learning and task specificity
closure improved, drinking from a straw or cup did in CP were investigated by Pinnington and Hegarty
not improve, which could be explained in terms of (2000), through a consistent method of food presen-
task specific learning. Oral motor exercises and muscle tation [56]. The commonly used posture for children
strengthening training have not been shown to be ef- with CP, positioned in the midline with neck flexion
fective in promoting feeding efficiency or weight gain during feeding, was combined with an often used rec-
in children and adolescents with CP suggesting that ommendation given to caregivers that food should be
strengthening interventions in isolation are neither ef- presented on a spoon with a relatively flat bowl, with-
fective nor worthwhile [50]. out scraping the utensil against the teeth. In the study
Traditionally, in case of aspiration on thin liquids, this was all achieved with a robotic arm that the chil-
thickened liquids are recommended. If we consider the dren could control themselves. Statistically significant
data from the Arvedson and colleagues study (1994), differences in components of oral motor behavior be-
dysphagia in CP is not only characterized by aspira- tween the assessment periods were found with this
tion on thin liquid, but residue after swallow is often consistent method of food presentation, which could
observed with the possibility of indirect/delayed aspi- not be attributed to maturation alone. This small study
ration [48]. In a study on the videofluoroscopic swal- showed the benefits of the training a specific oral motor
lowing recordings of 112 children with neurologic con- behavior during feeding. It supports the idea that also
ditions (CP and neuromuscular disorders) direct aspi- in CP children, with the use of clearly described ad-
ration on thin liquid in the CP group was observed. vices and techniques, motor learning for specific tasks
However, indirect/delayed aspiration was additionally could be beneficial.
seen as a result of pharyngeal post swallow residue
with pureed food [52]. Thickening liquids poses prac- 4.4. Progressive feeding and swallowing disorders
tical problems for caregivers and research has shown
that thickened liquids are difficult to mix precisely. In children and young adults with neuromuscu-
Although thickness or viscosity is often the focus of lar disorders (NMD) or muscle diseases, such as
measurement, other material property characteristics spinal muscular atrophy (SMA), myotonic dystro-
of the internal structure of the liquid, such as density phy or Duchenne muscular dystrophy (DMD) feeding
and yield stress, affect the way that thickened liquids problems and dysphagia may develop slowly. In chil-
move and behave [53]. The International Dysphagia dren with NMD malnutrition, impaired chewing per-
Diet Standardization Initiative (www.IDDSI) has re- formance and oral phase problems, choking and post-
cently developed global standardized terminology and swallow residue are described [57]. The common el-
definitions for texture modified foods and thickened ement in all NMDs is muscle weakness, which influ-
liquids to be used with individuals with dysphagia. The ences motor abilities and oral motor activities for feed-
terminology could also be helpful for clinical practice ing and swallowing, being influenced by the specific
in infants and children. muscle groups affected by the NMD. The oral phase
Head and trunk stability, in combination with align- of swallowing can be affected, resulting in drooling of
ment of oral structures, are important in feeding and saliva, losing food out of the mouth, mastication prob-
swallowing [54]. The postural difficulties of children lems, piecemeal deglutition, poor bolus formation, and
102 L. van den Engel-Hoek et al. / Pediatric feeding and swallowing rehabilitation

oral residue after swallow. Many children with NMD did not improve. The specific task of mastication was
need more time to complete their meals due to these trained and improved, again highlighting the benefits
oral phase problems. Pharyngeal phase problems can of task specific training.
range from residue after swallow in the valleculae, pir- It is important to realize that different progressive
iform sinuses and pharyngeal wall to penetration of neuromuscular disorders will follow a specific trajec-
food above the vocal folds or aspiration, more with tory in terms of the involvement of oral muscles, re-
solid food than with thin liquid [52]. sulting in different signs and symptoms of dysphagia.
NMDs are often complicated by oral motor and Therefore knowledge of dysphagia and its different
structural anomalies, which may negatively influence presentations with pediatric NMDs is important to en-
the oral phase of swallowing. A wide range of struc- able SLTs to design tailored interventions to suit indi-
tural difficulties are reported, such as malocclusions, vidual needs [68].
limited mouth opening, tented upper lip, high arched
palate, an atrophic or hypertrophic tongue, and dys-
trophic oral muscles [58–61]. In DMD oral muscles 5. Conclusions
have been visualized and dystrophic changes were
quantified using muscle ultrasound [62]. It has been Knowledge about pediatric feeding and swallowing
shown that the range of movement of the oral mus- and the management of dysphagia have greatly im-
cles gradually decreased over time, reflecting the in- proved during the past two decades. Normal motor
creasing influence of structural dystrophic changes. development of feeding and swallowing may be dis-
The echogenicity of the oral muscles showed the same rupted by a sudden deficiency in a particular skill re-
gradual involvement as observed in various skeletal sulting in inefficient or unsafe feeding and swallow-
muscles, but at a later onset. These dystrophic changes ing. The development may also be delayed, e.g. in chil-
in skeletal and oral muscles were found to be related dren with neurodevelopmental disabilities, or children
to muscle weakness [62,63]. The oral muscle weak- may gradually experience more feeding and swallow-
ness in this patient group causes more problems with ing problems in case of a progressive disease [39].
thick liquid and solid food. Rehabilitation in these pa- Growth, nutrition, hydration, prevention of aspiration
tient groups must focus on compensatory strategies pneumonias and quality of life should always be the
and low intensity training. Compensatory strategies main goals in feeding and swallowing therapy.
are described in terms of modifying consistencies, i.e. In recent years the treatment of feeding and swal-
smaller pieces of chewable food, less solid food and lowing disorders in children with developmental dis-
more thin liquid, and modifying posture. Children with abilities has increasingly focused on using motor learn-
SMA frequently have a retracted head posture. Adjust- ing approaches. Studies have resulted in a shift from
ing the head to a more upright position can lead to less using oral motor exercises, aimed at improving com-
pharyngeal post swallow residue and a better swallow- ponent skills, to task specific training during functional
ing when eating solid food [64]. everyday mealtimes with the focus on motor learning
The early involvement of masticatory muscles in to minimize risks associated with feeding and swallow-
DMD is an explanation for chewing problems and an ing disorders. Functional training should be used to im-
open mouth posture in early stages of the disease [65]. prove motor skills [42]. The best practice for eating is
From other studies with DMD it is known that disuse the act of eating itself. This contrasts with a bottom-up
leads to deterioration, and research has shown that a approach in which individual motor skills, such as jaw,
low-intensity physical training is beneficial in terms of lip and tongue exercises, are trained in the expectation
preservation of muscle endurance and functional abil- they will be combined and generalized to the task of
ities [66]. This principle was extrapolated to chewing eating.
and a study with mastication training was performed So, for practicing feeding skills one might argue:
with the use of one piece of sugar-free chewing gum “a child learns to eat with a spoon when it is actu-
per exercise (3 × 30 min/day, 5 days/week, 4 weeks ally fed with a spoon”. An understanding of the con-
long). The masticatory performance was assessed us- cepts of motor control and motor learning, as well as
ing a mixing ability test and the anterior bite force knowledge of the normal development of feeding and
was measured. The masticatory performance in the in- swallowing, the presenting problems in different pa-
tervention group improved and the improvement re- tient groups, the influence of food properties (i.e. dif-
mained after the one-month follow-up [67]. Bite force ferences between thin and thick liquid), and of oral
 L. van den Engel-Hoek et al. / Pediatric feeding and swallowing rehabilitation 103

motor activities in the oral phase and food transport in [14] Sweazey RD, Bradley RM. Response characteristics of lamb
the pharyngeal phase has become important for SLTs pontine neurons to stimulation of the oral cavity and epiglot-
tis with different sensory modalities. J Neurophysiol. 1993;
working with children and young people with feeding 70(3): 1168-80.
and swallowing disorders. [15] van den Engel-Hoek L, van Hulst K, van Gerven M, van
Haaften L, de Groot S. Development of oral motor behavior
related to the skill assisted spoon feeding. Infant Behav Dev.
2014; 37(2): 187-91. doi: 10.1016/j.infbeh.2014.01.008.
Conflict of interest [16] Dayan E, Cohen LG. Neuroplasticity subserving motor
skill learning. Neuron. 2011; 72(3): 443-54. doi: 10.1016/
All authors declare no conflict of interest. j.neuron.2011.10.008.
[17] Robbins J, Butler SG, Daniels SK, Diez Gross R, Langmore S,
Lazarus CL, et al. Swallowing and dysphagia rehabilitation:
translating principles of neural plasticity into clinically ori-
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