Private feeding evaluation therapy in Manhattan, NYC.
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Eating is a primary human activity needed for survival. But for very young children, feeding can be a complicated task that needs complex coordination of different oral motor skills—biting, chewing, and finally, swallowing. Most babies and toddlers learn instinctively over time how to suck, bite, chew, and swallow food and how to drink from a nipple, straw, and cup. But there are some who demonstrate difficulty learning these oral motor skills, interfering with their feeding development.

Young children begin their feeding journey by first learning how to suck liquids then chew single grain cereals or pureed food. When introducing solids, it is a messy process that needs plenty of practice and monitoring from parents. Certain difficulties like gagging, pushing food back, spills, and trouble with swallowing are normal and correct themselves over time.

Likewise, children with a feeding delay or disorder, they may exhibit a difficulty transitioning from one food type to the next. These challenges will persist as they get older if not addressed or given adequate feeding therapy.

Pediatric feeding disorders are characterized by challenges in oral intake that are not typical for a child’s age. It often involves delays and difficulties in eating, drinking, chewing, sucking, and swallowing as well as food aversions, food refusal, and food and texture selectivity. Swallowing problems or dysphagia refers to problems in one or more areas of the three phases of swallowing. These phases or stages are:

  • Oral phase – The sucking, chewing, and moving of food or liquid into the throat. Feeding is part of the oral phase.
  • Pharyngeal phase – The squeezing of food down the throat, which begins the swallowing action.
  • Esophageal phase – The opening and closing of the esophagus as it squeezes food down to the stomach.

How Feeding Therapy Helps

A feeding disorder can occur alongside developmental delays or medical conditions, such as autism spectrum disorder, Down syndrome, cerebral palsy, or respiratory disorders.

Young children with feeding difficulties typically demonstrate a delay in or difficulty swallowing, sucking, chewing, and display food aversions, food refusal, texture selectivity, and food selectivity. Many factors can cause a young child to become a picky eater.

Feeding therapy involves improving the the child’s oral motor and underlying feeding skills and their eating habits. We assess the child’s sucking, swallowing, chewing patterns, diet, behavior, and the home environment during meal time time. Once we pinpoint the underlying problem(s), we create a family treatment plan. Some children require additional one-on-one feeding therapy, and we demonstrate to the parent how to tackle their child’s feeding or eating delay.

Read about Early Childhood Developmental Milestones.

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Causes of Feeding Disorders

Several factors can cause a child’s feeding and swallowing disorder. Infants who were hospitalized at birth and received tracheotomy for an extended time will often have difficulties adopting proper feeding patterns. In some cases, even children with no known conditions or relevant medical histories can develop a fear of food.

Other possible factors that could lead to feeding and swallowing disorders include:

  • cerebral palsy, meningitis, and other nervous system disorders
  • autism
  • stomach problems, such as reflux
  • premature or low birth weight
  • heart disease
  • cleft lip or palate
  • asthma or other respiratory problems
  • muscle weakness in the face and neck and other head or neck problems
  • medication that causes sleepiness or loss of appetite
  • sensory issues
  • behavioral problems

Signs and Symptoms of Feeding and Swallowing Disorders

Feeding and swallowing disorders in children are often difficult to spot at first. Most of the time, children who struggle during mealtimes are simply assumed to be picky eaters. And while this is true for many, there are other signs and symptoms that family members can consider to distinguish between a child who is a picky eater or one with a feeding problem. These include:

  • back arching and stiffening during meal times
  • crying, fussing, or falling asleep when feeding
  • throwing tantrums when presented with new or unfamiliar foods
  • trouble breathing while eating or drinking
  • coughing, choking, or gagging during meals
  • preference for specific textures of food (crunch or soft food) or aversion to a particular food group
  • taking a long time to eat or simply refusing
  • struggling to chew or swallow
  • excessive drooling during meals, has liquid come out of mouth or nose, or gets stuffy
  • frequently spitting or throwing up
  • not gaining weight or growing
  • eating less than 20 types of foods
  • refusing to eat meals with the family or a group

Meanwhile, a child who is a picky eater may sometimes exhibit similar behaviors as someone with a feeding disorder. However, there are key differences to monitor. Typical signs of a picky eater are:

  • eats a limited variety of foods (around 30 types)
  • consumes enough calories daily for growth and nutrition
  • often loses interest in a particular food but will accept it again after a certain period
  • accepts and eats at least one food from all food groups
  • allows new or unfamiliar food on the plate even if they do not touch or eat it

Manhattan Letters Feeding Evaluation Therapy
How Feeding Evaluation and Feeding Therapy Work

Treatment for feeding or swallowing disorders starts with getting a comprehensive check on the child’s general health. A pediatrician can assess the child’s growth and weight based on what is appropriate for his or her age. Children must also be checked for any condition that interferes with feeding skills.

If your child’s doctor determines that there is cause for concern, a speech-language pathologist (SLP) may be consulted to conduct a feeding evaluation and provide a diagnosis.

During the feeding evaluation, the speech-language pathologist will:

  • ask questions about the child’s medical history and overall development
  • observe how the child moves his or her mouth, tongue, and jaw when eating and drinking various foods and liquids.
  • watch how the child eats and take note of the way he or she picks up food, chews, swallows, and drinks
  • observe the child’s behavior during meals
  • consider the parent child interactions
  • assess mealtime routines
  • conduct additional special tests, if necessary

Once a diagnosis is made, the SLP or therapist may work closely with a team to design a feeding therapy plan to address the child’s needs. This team may include a physical or occupational therapist, a dietitian or nutritionist, a physician or nurse, or a developmental specialist.

As part of the multidisciplinary team, the SLP can help your child address the following issues:

  • improving the child’s tongue and jaw movement
  • Improving the child’s lateral chewing
  • introducing new foods and drinks
  • improving the way the child sucks from a bottle or drinks from a cup
  • adjusting textures of food and thickness of liquids to make swallowing easier
  • encouraging the child’s good behavior during meals, such as increased focus at meal times, not refusing food, and not fussing
  • addressing the child’s sensory issues (how the food feels in his or her mouth or hands)

The SOS Approach to Feeding

The Sequential Oral Sensory (SOS) approach to feeding therapy addresses not only the child’s needs and eating difficulties but also its underlying causes. It is based on the feeding steps, stages, and skills found in typically developing children. The SOS approach relies on several factors, including motor, oral, behavioral/learning, medical, sensory, and nutrition, in determining the root cause of a child’s feeding problems and managing it successfully.

In conducting SOS feeding therapy, it is important to create an environment wherein a child can interact and get familiarized with food in a non-stressful way. Feeding therapy may be done individually, as a group, or at home, with the primary goal of helping the child develop and master the necessary skills to become a healthy and safe eater.

Feeding therapy meals are done to help children work on feeding skills and expose them to new foods. It typically starts with foods the child is already familiar with and able to tolerate before moving on to new ones. The therapist encourages the child to smell the food, learn about its texture, and explore its taste. Modeling and reinforcement are crucial during feeding therapy in order to help the child develop a positive relationship with food.

The SOS approach can also be applied during family meals, wherein the goal is to improve the volume or amount of the child’s food intake. Pediatric feeding therapists use several strategies that may include:

  • Serving a piece or spoonful of every food offered on the child’s plate. Whether the child eats it or not, the goal is to familiarize them with the food’s texture, smell, color, and where it comes from.
  • Including at least one food that the child is guaranteed to eat in order to expose the child to new foods while still ensuring they are eating the right amount of food.
  • Parents modeling good eating habits and describing the food and its taste.
  • Praising the child’s attempt to eat or explore new foods but taking care to not let the child be the sole focus of the meal.

At Manhattan Letters, our pediatric feeding therapy involves improving the underlying feeding skills and eating habits of babies, toddlers, and preschoolers. We assess the child’s sucking, swallowing, chewing patterns, diet, behavior, and the home environment during meal time time. Once we pinpoint the underlying problem(s), we create a family treatment plan. Some children require additional one-on-one feeding therapy. Our pediatric feeding therapists work closely with parents on how to tackle their child’s feeding or eating delay.


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NY State licensed speech-language pathologist, Certificate of Clinical Competence in Speech-Language Pathology (CCC-SLP)

Pediatric dysphagia (known more commonly as pediatric feeding/swallowing) is a speciality area within speech-language pathology that involves additional coursework and training beyond traditional speech and language training. Pediatric feeding therapists can work with a wide range of clients- babies/children with a history of prematurity and a stay in the neonatal intensive care unit (NICU), those with neurological, genetic, or cardiac conditions, reflux/GERD, poor weight gain, bottle or food refusal behaviors, babies with difficulty sucking, babies/ children with oral motor delays and difficulty transitioning to solids, or babies/children being tube fed. 

During the initial feeding and swallowing evaluation, a full medical and feeding history will be taken. Often, if a child sees an ENT, GI, or nutritionist, those notes will be reviewed as well (the therapist will also make referrals to such specialists if needed). The therapist will perform an oral mechanism exam to make any observations about the oral motor structures that could impact feeding, observe a feed ( breast/bottle/cup/solids etc) to assess both feeding and swallowing skills, and make recommendations as needed. 

A pediatric feeding therapist will look at feeding skills:

  • The therapist will look at a child’s oral motor structures and function ( how are the lips, cheeks, tongue, and palate working together to support bottle/breast feeding or transition to solids?
  • How efficient is a baby when bottle feeding ( does it take a long time to drink from the bottle? Does the baby seem to be working very hard to get a small amount of milk out of the bottle?)
  • How is a baby or child doing once transitioning to purées and solids? Is he chewing appropriately or gagging and vomiting?

While also observing swallowing skills:

  • how is the baby handling the milk once they begin swallowing. Is the suck-swallow-breathe mechanism needed for safe and efficient feeding within normal limits or does there need to be a change in position,bottle, or other feeding techniques to help the baby?
  • Is the baby or child coughing frequently with food or liquid?
  • Is the baby showing signs that the liquid flow rate is too fast or too slow? How is their breathing and overall state during a feed? 
  • Does the baby or child have a diagnosis of “aspiration” where food or liquid is known to go into the airway and need a special diet?

After a full evaluation, treatment can be provided as needed. Typically for babies and young children, feeding therapy looks different than traditional speech, physical, or occupational therapy. More traditional therapy is usually 1-3 times a week for 30-45 minutes for multiple weeks or months.  During the initial feeding/swallowing evaluation, which is typically between 60-90 minutes, parents are given a lot of education and functional treatment ideas/things to work on before the next follow up. 

Follow-ups ( if needed) are scheduled as needed and are usually periodic to allow time for parents to practice the techniques provided at the evaluation and to allow the baby/child to make progress in a developmentally appropriate time frame. Treatment frequency is very child and family specific. For most clients treatment/follow-up may look like:

  • 1x per week for a month OR
  • 2x a month for 1-2 months OR
  • once a month follow-up OR
  • on an as-needed basis

Treatment is typically 45 minutes. Treatment plans are very specific and individualized and during the initial evaluation will be discussed with families. 

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