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Swallowing and feeding in infants and young children

Joan C. Arvedson, Ph.D., M.S.

Key Points

Normal development of feeding and swallowing is an important basis for understanding feeding

and swallowing disorders in infants and children. Critical and sensitive periods are important considerations in developmental expectations for

expanding textures in young children.

Pertinent questions to determine if further investigation of feeding and swallowing is needed:o If meal times takes more than 30 minutes on average.

o Are meal times stressful?o Does the child show signs of respiratory stress?o Has the child notgained weight in the past 2 to 3 months?

Most children with complex feeding and swallowing problems are best served by aninterdisciplinary team.

Videofluoroscopic swallow study (VFSS) or flexible endoscopic examination of swallowing(FEES)are needed to define pharyngeal physiology with risks for aspiration or other pulmonary

problems

Intervention strategies must not jeopardize nutrition and hydration, nor should they be stressful to

infants and children. Outcomes of therapy depend on multiple interrelating systems, including neurologic status,

airway protection, and integrity of gastrointestinal (GI)tract.

Introduction

Adequate respiration and nutrition are essential throughout a lifetime. Breathing usually does not require

active effort by infants except for those with complicating factors, for example, bronchopulmonarydysplasia (BPD) leading to chronic lung disease (CLD), upper airway obstruction as in Pierre Robinsequence (PRS), other craniofacial anomalies, and severe laryngotracheobronchomalacia. Eating, on the

other hand, requires active effort by infants who must have exquisite timing and coordination for sucking,swallowing, and breathing at the breast or bottle. Adequate growth, defined by weight gain in early

infancy and for the first few years of life, is the primary measure of successful feeding. Feeding,swallowing, and respiration are activities that occur in the upper aerodigestive tract and are orchestratedby specific areas in the brain and cranial nerves. Successful oral feeding requires that children havefunctional oral sensorimotor and swallowing skills, overall adequate health (including pulmonary andgastrointestinal function), central nervous system integration, and musculoskeletal tone. A breakdown in

coordination of swallowing and breathing can result in aspiration, which, over time, can progress tobronchiectasis. Aspiration may present with coughing and choking, usually during feeding, and isindicative of compromised airway protective reflexes. If laryngotracheal sensation is also affected,aspiration may be silent without any overt manifestations.

Successful emergence of communication skills relates to successful feeding and swallowing. Normalfeeding patterns reflect the early developmental pathways that are the basis for later communication

skills. The interrelationships between feeding (in all living beings) and complex verbal communication(unique to humans) are multifactorial and in need of continued research. The study of comparative

anatomy and its implications for human communication are well described.1

Professionals who examine and treat infants and children who have feeding and swallowing problemsmust have a thorough understanding of embryologic and developmental anatomy of the upperaerodigestive tract and the physiology of deglutition. Research in the past 30 years has added to the

understanding of the orderly development of feeding and swallowing in utero through infancy.
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Incidence and Prevalence of Feeding and Swallowing Disorders in Pediatrics

Feeding and swallowing disorders are relatively common in early infancy and in some instances may bemarkers for significant health implications that do not become obvious until later. As many as 35% ofinfants exhibit food selectivity and refusal, as revealed by parent interviews in general population surveys.Feeding problems are relatively common in various infant populations, including, but not limited to,

preterm "at-risk" infants, infants with congenital heart disease following open-heart surgery, infantsdiagnosed with nonorganic failure to thrive, and children with cerebral palsy (CP). Prevalence rates ofdysphagia range from 57% to 92% varying by type ofCP.2Children withCPand dysphagia are found tohave a higher incidence of undernutrition, growth failure, and poor health than those children without

swallowing problems. Children with more severe forms ofCPand dysphagia have higher mortality ratesthan other groups.

This review provides an overview of (1) the development of feeding and swallowing skills, includingcritical/sensitive periods with implications for behavioral and sensory based feeding problems; (2) taste

and smell, and their impact on oral feeding; (3) clinical assessment; (4) instrumental examination ofpediatric swallowing disorders; and (5) management of pediatric feeding and swallowing disorders.

Development of Feeding and Swallowing SkillsPrenatal Swallowing and Sucking

In utero studies of fetuses have documented the early development of swallowing and oral-motorfunction3(Table 1). In utero swallowing is important for the regulation of amniotic fluid volume andcomposition, recirculation of solutes from the fetal environment, and the maturation of the fetal

gastrointestinal tract.4The pharyngeal swallow, one of the first motor responses in the pharynx, has beenobserved between 10 and 12 weeks' gestation.5Recent studies have demonstrated swallowing in most

fetuses by 15 weeks' gestation and consistent swallowing by 22 to 24 weeks' gestation.3

Table 1: Gestational ages for swallowing and sucking

True suckling begins around the 18th to 24th week and is characterized by a distinct backward andforward movement of the tongue. The frequency of suckling motions can be altered by taste. Taste buds

are evident at 7 weeks' gestation. By 12 weeks' gestation, distinctively mature receptors are noted. Selforal-facial stimulation usually precedes suckling and swallowing. Tongue cupping is seen by 28 weeks'

gestation.

This backward and forward movement of the tongue in suckling is all that can be expected because thetongue fills the oral cavity at this stage of development. Backward movement appears more pronouncedthan forward movement. Tongue protrusion does not extend beyond the border of the lips. Serialultrasound images have shown that suckling motions increase in frequency in the later months of fetallife.3By 34 weeks' gestation, a healthy preterm infant likely suckles and swallows well enough to sustain

nutrition strictly through oral feedings. Some healthy preterm infants may be ready to begin oral feedingby 32 to 33 weeks' gestation.
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It has been estimated that the near-term human fetus swallows 500 to 1000 mL/day of amnioticfluid.4Earlier reports had indicated that the fetus swallows about 450 to 500 mL of amniotic fluid per day

(of the total 850 mL) and excretes about the same amount in urine.6Decreased rates of fetal suckling are

associated with digestive tract obstruction or neurologic damage. Intrauterine growth retardation may be amanifestation of neurologic damage. Lack of regular swallowing by the fetus should lead one to suspect

problems that may be related primarily to the preterm infant or primarily to the mother. Maternal

polyhydramnios characterized by excessive amniotic fluid in the uterus may result from multiple fetal andmaternal etiologies. Severe polyhydramnios is more strongly associated with congenital malformationsthan mild or moderate polyhydramnios.

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Infant Feeding and Swallowing

Oral feeding that requires suckling, swallowing, and breathing coordination is the most complex

sensorimotor process the newborn infant undertakes. Premature infant patterns differ from those of full-term infants. Five primary developmental stages of sucking characterized the maturational process (Table2).8Sucking patterns in infants born at less than 30 weeks' gestation were monitored from the time theywere introduced to oral feeding until they reached full oral feeding. The five-stage scale demonstrates the

relationship between the development of sucking and oral feeding performance in preterm infants. A high

interobserver reliability was observed on 50 bottle-feeding assessments. The authors suggest that there isno significant in utero maturation of sucking occurring between 26 and 29 weeks' gestation, or they hadinsufficient statistical power to detect a difference over this developmental period. A significantcorrelation between the level of maturity of an infant's sucking and gestational age was found. Feeding

performance correlated with progression of oral feeding. These authors suggest that developmental scalescan be used clinically for the identification and characterization of the oral sensorimotor skills of preterminfants at any point in their development as they progress in their individual oral feeding schedule.Objective and quantitative evaluations of infants' nonnutritive and nutritive sucking would be helpful inevaluating strength and coordination. One proposal includes a finger pressure device to allow for

quantification of specific measures of nonnutritive sucking in combination with a nipple/bottle systemdeveloped for monitoring nutritive sucking.9However, there is no standardized quantifiable procedureavailable currently.

Table 2: Five primary stages of sucking in preterm infants

Term infants typically show food-seeking behavior through rooting for a breast or other nipple for bottlefeeding. Preterm infants gradually achieve skills for rooting, suckling, and swallowing for functional oral

feeding as they advance toward term. Important early developmental milestones and feeding skills from

birth to 36 months are shown inTable 3.Children older than 36 months typically are eating regular tablefood and drinking from an open cup. They continue to refine their skills, but they do not attain new skills.Thus, this review focuses on feeding and swallowing in infants and young children.

Table 3: Developmental milestones and feeding skills birth to 36 months
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Critical and Sensitive Periods with Implications for Behavioral and Sensory-Based Feeding

Problems

The concept of critical and sensitive time periods in overall human development is well documented insome areas of development and in animal research. Lorenz

12interpreted findings from animal

embryologic studies to imply that there is a period during early development when the organism is primed

to receive and perhaps permanently encode important environmental information. These interpretationsdo not mean that later learning cannot occur or that it is not important, but they do emphasize the possible

significance of these early experiences.Critical and sensitive periods are believed to exist in the development of normal feeding behavior.Descriptions of these critical periods typically focus on the introduction of chewable textures (Table 3).Children develop oral side preferences for chewing that relate to hand preferences in many instances.Chewing skills vary with textures. Children develop mature chewing skills for solid foods earlier than for

viscous and pureed foods. However, it is common for children who have not mastered the timing andcoordination for swallowing purees and other smooth food to be kept on those textures because caregiversmay believe that these children are not ready for introduction of chewable food, which is not necessarily

true. Children need to be introduced to solid foods at the most appropriate times. Children may rejectsolids upon initial presentation if they are introduced after the critical periods. The longer the delay in the

introduction of solids, the more difficult it is for many children to accept chewable food. Withholdingsolids at a time when a child should be able to chew (6 to 7 months developmental level) can result infood refusal and even vomiting,13which in turn may have a significant negative effect on nutrition and

hydration status.

Studies in mice reveal that those fed a soft-feed (powdered) diet after weaning reduced synaptic formationin the cerebral cortex and impaired the ability of spatial learning (radial maze) in adulthood whencompared with mice fed a hard-feed (pelleted) diet.14Similar deficits may result from lack of experienceand exposure to age-appropriate foods in humans, providing a conceptual framework to explain clinical

observations of the challenges encountered in the learning of oral sensorimotor and other skills in childrennot fed during critical/sensitive periods for oral skill development. Perhaps when children have not beenintroduced to solid foods within the critical sensitive periods, broad aspects of development may be

affected negatively. One may assume that these children missed not only this critical period for chewing,but also the underlying skills, which include trunk stability, head control, mobility of limbs, and mouthingexperiences involving hands, fingers, and toys. Physiologic processes that are underpinnings for oralsensorimotor and swallowing skills, such as respiratory control, also have critical periods that can impactthe feeding process.

Psychosocial development, personality, and environment are additional factors that must be consideredfor children with feeding issues. Some children may respond in aversive ways when presented withcertain textures, tastes, or temperatures of food and liquid. These same children may be hypersensitive to

tight clothes or tags on their clothes. They may not like to wear shoes. They may get upset when theirhands get dirty, so they refuse to do finger painting and will not put their fingers into pudding or other

pureed food.

Critical and sensitive periods may apply to the mother, with effects related to the potential for efficientfeeding and global development of an infant.

15Maternal early contact with both preterm and term infants

has been found to have a positive effect on the mother's attachment behavior and ultimately enhanced

development of the infant.

Effects When Oral Feeding Is Not Possible in the Newborn Period
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When infants with major physical and physiologic problems are prevented from initiating oral feeding inthe same time frames as their more typically developing peers, many demonstrate prolonged delays and

significant difficulty with oral feeding. In addition, significant variations are found in the form andfunction of the ingestive systems of age-matched healthy infants and at-risk infants. Ultrasounds revealedthat fetal swallowing occurred most commonly in the presence of oral-facial stimulation. Hands weretouching face and mouth. In some instances, fingers or thumbs were seen in the mouth. Perhaps some

infants miss critical periods while still in the womb. Miller and colleagues3postulate that prenataldevelopment indices of emerging aerodigestive skills may guide postnatal decisions for feeding readinessand, ultimately, advance the care of medically fragile neonates. Clinicians must have knowledgeregarding normal development in order to appreciate and understand the implications of differences ininfants and young children with feeding and swallowing problems, which are likely to be just one or two

pieces of a much larger and more complex puzzle. All aspects must be delineated in order to plan

management strategies that will permit adequate nutrition without pulmonary issues and without stress tothe child as well as to the caregiver.

Taste and Smell in Oral Feeding of Infants and Young Children

Understanding an infant's awareness of taste and smell, along with responses to textures and temperature,is fundamental for clinicians of any discipline to determine the potential for acceptance of new foods.

Physicians, dietitians, nurses, and therapists who guide parents when children are failing to thrive, or havelimited range of foods in the diet, must examine the broad parameters that can impact on a child's feedingstatus. These experiences occur much earlier than many professionals would expect. Initial experienceswith flavors occur prior to birth, because the flavor of amniotic fluid changes as a function of the dietarychoices of the mother. Flavors from the mother's diet during pregnancy are transmitted to amniotic fluid,

which are not only perceived by the fetus, but enhance the acceptance and enjoyment of that flavor in afood during weaning from the breast. The ability to detect additional tastes and flavors develops after

birth. Thus, it is clear the early sensory experiences have an impact on the acceptance of flavors and foodsduring infancy and childhood.16It has long been shown that human infants are born with a preference for sweet. Their sensory apparatus

can detect sweet tastes. Tatzer and colleagues17found that preterm infants fed exclusively via gastrictubes exhibited more nonnutritive sucking in response to minute amounts of glucose than to watersolutions presented intraorally. Infants produced more frequent and stronger sucking responses whenoffered a sucrose-sweetened nipple compared with a latex nipple.18Exposure to flavors in breast milk may serve to heighten preferences for these flavors and facilitate the

weaning process. Some breast-fed infants are more willing to accept a novel vegetable upon firstpresentation than are formula-fed infants.19Children who have been breast-fed for at least 6 months are

also less likely to become picky eaters.20

The ability to detect and prefer a salt taste does not appear until infants are about 4 months of age. Animal

model studies demonstrate that this developmental change may reflect postnatal maturation of central andperipheral mechanisms underlying salt taste perception.21The preference that emerges at this age appearsto be largely unlearned.

An example of the importance of early exposure to flavors is found in the acceptance of proteinhydrolysate formulas by 7-month-old infants who had readily accepted this kind of formula whencompared to their regular milk- or soy-based formula in the first couple months of life. These formulas

are known by a variety of names depending on the company that produces and distributes them in theUnited States and in other countries throughout the world. A sensitive period in early infancy is suggested

as at least one important factor, as shown by the finding that those infants 7 months and older avidlyaccept these formulas if they have experienced them during the first months of life. However, in markedcontrast, 7- to 8-month-old infants who had no previous experience with hydrolysate formulas stronglyrejected them and displayed extreme and immediate facial grimaces, similar to those observed innewborns in response to bitter and sour tastes.22
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Professionals who make decisions regarding feeding of infants and young children have to considermultiple variables. Differences in flavor acceptance that occur from breast-fed to bottle-fed infants and

that likely change over time reflect complex interactions of sensory and motor factors.

Clinical Assessment of Pediatric Swallowing and Feeding Disorders

Screening Questions for Primary Care Physicians

There are four key questions that physicians and nurses in primary care can ask parents when an infant oryoung child presents at the office or clinic with parental concerns related to feeding. The answers helpdetermine if a comprehensive clinical feeding and swallowing assessment is needed, even though the

answers do not necessarily define the problem:

How long do mealtimes typically take? If more than about 30 minutes on any regular basis, thereis a problem. Prolonged feeding times are major red flags pointing to the need for furtherinvestigation.

Are mealtimes stressful? Regardless of descriptions of factors that underlie the stress, furtherinvestigation is needed. It is very common for parents to state that they "just dread mealtimes."

Does the child show any signs of respiratory stress? Signs may include rapid breathing, gurglyvoice quality, nasal congestion that increases as the meal progresses, and panting by an infantwith nipple feeding. Recent upper respiratory illness may be a sign of aspiration with oral feeds,

although there may be other causes. Has the child not gained weight in the past 2 to 3 months? Steady appropriate 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 a weight loss in an older child or adult.

Principles of Clinical Feeding Evaluation

The clinical evaluation of an infant or child with complex issues related to feeding and swallowingincludes a thorough history, physical examination, and feeding observation. Instrumental assessments ofswallowing may be needed following the clinical evaluation when concerns are noted regarding

pharyngeal phase physiology and risks for aspiration with oral feeding. Most children are best served in

the context of an interdisciplinary team. Unfortunately, such teams are available only in a limited numberof medical centers in the United States and in other countries throughout the world. Information is

provided that should be useful for physicians, dietitians/nutritionists, and other professionals who do nothave an interdisciplinary team available. All professionals who work with these infants and children are

urged to collaborate with appropriate colleagues, and to develop an interdisciplinary team to whateverextent is possible. Particular attention is paid to factors that are likely to interfere with adequate nutritionand hydration, because the most fundamental goals for all children relate to optimal status of nutrition and

hydration.

Categories of Causes of Swallowing and Feeding Disorders

A careful reading of the medical, developmental, and feeding history is the first step that is critical todecision making. Swallowing and feeding disorders in infants and children are complex and can have

multiple causes in various categories of disorders including, but are not limited to: Disorders that affect hunger/appetite, food-seeking behavior, and ingestion

Anatomic abnormalities of the oropharynx

Anatomic/congenital abnormalities of the larynx and trachea

Anatomic abnormalities of the esophagus


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Disorders affecting suck-swallow-breathing coordination

Disorders affecting neuromuscular coordination of swallowing

Disorders affecting esophageal peristalsis Mucosal infections and inflammatory disorders causing dysphagia

Other miscellaneous disorders associated with feeding and swallowing difficulties, for example,xerostomia, hypothyroidism, trisomy 18 and 21, Prader-Willi syndrome, allergies, lipid and

lipoprotein metabolism disorders, and a variety of craniofacial syndromes.

Link and Rudolph23have a detailed list of specific causes within each of the above categories.

Caregiver Perceptions of Feeding Problems

Each person involved with feeding and caring for a child is likely to have perceptions of the feeding statusand problems that differ from other caregivers and professionals. Information is needed from more than

one caregiver or professional involved with the child. Questions are formulated to delineate the feedingstatus as clearly as possible. The following questions go beyond the screening questions suggested earlier:

How long does it take to feed the child?

Prolonged meal/feeding times that are more than 30 to 40 minutes on a regular basis in most cultures isone of the major markers of some kind of feeding problem for infants and children of any age, whetherinfants are strictly nipple feeding or children are on a broader range of food and liquid. Prolonged meal

times in isolation would not define the nature of the problem. Prolonged feeding times may relate to oralsensorimotor deficits, airway issues and risks for aspiration, and parent-child interaction or behavioral

based problems.

Is the child independent for feeding or dependent on others to a greater degree than would be expectedfor age and overall developmental status?

Independent feeders usually, but not always, have better coordination for functional swallow productionthan those with neurologic etiologies that make it difficult to hold the head upright or to produceswallows without delay. Children with quadriplegic cerebral palsy who are dependent feeders maydemonstrate reduced oxygen saturation during feeding.24They are more likely to be silent aspirators than

children with overall better neuromuscular strength and coordination.25

Is the child a total oral feeder?

If the answer is yes, is the nutrition status adequate? If the child is not a total oral feeder, are nutritionneeds met by a combination of oral and tube feedings? Many caregivers perceive total oral feeding as amarker of success for the child as well as for parenting. However, if the child is at risk for undernutrition,tube feeding allows for nutrition and hydration needs to be met without placing undue risk on therespiratory system and/or the energy levels required for feeding orally, as well as parent-child interaction

stress.

Do differences in food textures, temperatures, or tastes change the child's response at mealtime?

Aspiration and pharyngeal deficits can be texture-specific in some children. Children with anatomicabnormalities, such as esophageal webs, strictures, vascular rings, or enlarged tonsils and adenoids, may

have difficulty progressing to solid foods. Children with incoordination of the oral and pharyngeal phasesof swallowing or with a delay in initiating a pharyngeal swallow are at greater risk for aspiration with thin

liquids than with thicker textures. Some children prefer sour or spicy food over bland food, crunchy vs.
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smooth, cold vs. warm, or vice versa. These attributes usually interact and have effects on the efficiencyand pleasure of feeding.

Does the feeding problem change throughout the course of the meal?

It is not unusual that children who are orally defensive demonstrate little to no hunger, have poorappetites, have postural problems, and have breakdowns in child-parent interactions. They often showmore difficulty before or at the beginning of meals and may improve as the meal progresses. Children

with oral sensorimotor and swallowing deficits may demonstrate more problems near the end of themealtime due to fatigue, compromised cardiopulmonary function, and oropharyngeal dysphagia.

Does the feeding problem vary by time of day or by feeder?

Environmental factors that can alter mealtime efficiency need to be explored. These environmental factorsmay involve different approaches or methods by different caregivers, possible distractions at mealtimes(e.g., other children, television, pets), appetite suppressants, and fatigue factors.

Does the child maintain a midline neutral position of the trunk, neck, and head without requiring addedsupport?

If the answer is no, what are the interfering factors? Some children with cerebral palsy as well as thosewith other neurologic diagnoses may show extensor arching of the trunk and extremities while feeding.

The risks for aspiration may be greater with this posture than for the child who sits upright with goodhead control. At the other extreme is the child with hypotonia who has a "floppy" neck. That child mayhave increased risk for aspiration because of excessive flexion of the oropharynx due to the "floppy"

neck.

Are there signs of breathing difficulties during feeding?

These signs may include rapid respiratory rate, panting (especially in infants while sucking andswallowing via nipple), increased nasal congestion, and gurgly voice quality. Any changes in respiratory

effort and/or rate should be investigated. The work of breathing takes precedence over the work offeeding. Signs of possible risks for aspiration with oral feeding must be followed up with appropriate

investigations, e.g., videofluoroscopic swallow study (VFSS), flexible endoscopic examination ofswallowing (FEES), esophagogastroduodenostomy (EGD), esophageal manometry, and computedtomography (CT)scan of the chest.

Does the child have emesis regularly?

If yes, when does it occur? Can parents estimate the volume per episode? Can parents predict the timing

of emesis in relation to feeding? Does the child "spit up" or have projectile vomiting? Children with

neurologic-based dysphagia have a high incidence of gastroesophageal reflux (GER) that ranges from15% to 65%. On the other hand, it is not unusual for children with gastroesophageal reflux disease(GERD)to have no emesis.26

Does the child refuse food?

If yes, when, where, and how often? What are the behaviors of refusal? Food refusal can occur for

multiple reasons, some of which are physiologically based and others that may be skill or behavior based.
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Physical/physiologic problems may have resolved some time in the past, but the negative experienceshave been so powerful that the child associates pain and discomfort with eating long after resolution.

Factors may relate to one or more of the following: airway, gastrointestinal (GI)tract, oral sensorimotor,and behavior (e.g., parentchild interaction problems). Infants and young children have limited ways tocommunicate their stresses. Thus, food refusal may be the way the child can let others know about pain ordiscomfort, or possibly the child may be exerting independence and control.

Does the child get irritable or sleepy and lethargic during mealtimes?

Irritability is one way that problems withGER,other gastrointestinal problems, and airway problems are

communicated. Irritability can also be a behavior response, but that is less likely than a physiologicresponse. Lethargy at mealtime may relate to excessive fatigue, recurrent seizures, or medications withsedative effects (e.g., anticonvulsants, muscle relaxants).

How do the child and caregiver interact? Are there signs of forced feeding?

Parental stress related to the feeding situation can be transmitted to a child, which in turn exacerbates thefeeding difficulties. Forced feeding seldom leads to feeding success. Complications are more apt to follow[e.g., food refusal, failure to thrive (undernutrition), and other more global behavior maladaptations].

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Interdisciplinary Team Approach

An interdisciplinary team approach offers the benefit of coordinated consultation and problem solving for

multiple interrelated problems. Effective management of these medically complex children depends onthe expertise of many specialists, who may work independently and as a team (Table 5). Casecoordination is often a critical component that is intensive and needed to optimize the child's health and

development along with the family's ability to cope with multiple issues and sometimes disparateopinions and recommendations. An interdisciplinary approach is recommended at institutions where

professionals evaluate and treat children with complex feeding and swallowing problems. Success factors

include the following:

Table 5: Feeding/swallowing team members and their functions

Collegial interaction among relevant specialists

Shared group philosophy related to diagnostic approaches and management protocols Team leadership with organization for evaluation and sharing of information Willingness to engage in creative problem solving and research

Time commitment for the labor-intensive work that is required

Depending on the expertise and interest in different institutions, team members may be drawn fromdifferent disciplines. The functions should cover those described (Table 5). Not all disciplines will beneeded for all children. It is important to determine which disciplines can best serve the child and family
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so that patient care can be both efficient and efficacious. Specific discipline involvement may change overtime as the child's needs change.

Instrumental Examination of SwallowingInstrumental examinations may be needed for infants and children particularly when the pharyngeal andesophageal physiology needs to be delineated objectively to answer specific questions related to the safety

and efficiency for oral feeding. Criteria for instrumental examinations of swallowing include, but are notlimited to:

Risk for aspiration by history and clinical observation

Observation of infants demonstrating incoordination of sucking, swallowing, and breathingduring oral feedings at breast or bottle

Clinical observation of older children with a variety of signs suggesting possible pharyngeal orupper esophageal phase swallowing deficits

Prior aspiration pneumonia or similar pulmonary problems that could be related to aspiration

Suspicion of pharyngeal or laryngeal problem on basis of etiology, particularly neurologicinvolvement that is common with feeding and swallowing problems

Gurgly voice quality

Need to define oral, pharyngeal, and upper esophageal phases of swallowing

Multiple factors are considered in making decisions about which examination and when it will be used.The decision regarding which instrumental examination is needed depends on the anatomic areas andfunctional processes to be assessed. Instrumental methods for evaluation of swallowing include

videofluoroscopic swallow study (VFSS), flexible endoscopic examination of swallowing (FEES), andultrasonography (US). Specific diagnostic questions can be answered to guide therapeutic decisions.

Other diagnostic assessments that do not measure swallowing directly may influence recommendationsrelated to swallowing (e.g., scintigraphy or salivagram).

Considerations for Instrumental Examinations

Protocols for and interpretation ofVFSSneed to be developmentally appropriate for the infant or child at

baseline health status and not during an acute illness or when unstable medically. Other considerationsinclude developmental function levels, positioning, bolus presentation, viscosity of bolus, respiratory rate,

and swallowing variability.27Fiberoptic nasopharyngolaryngoscopy (FNL) with infants is primarily forassessment of the anatomy and physiology of the upper aerodigestive tract. Observations of swallowsmay be incorporated as needed. A modification of this procedure,FEES,is focused directly on observing

the pharyngeal phase of swallowing, although it is less complete thanVFSS;FEEScan include sensorytesting.

28Ultrasonography has been used to study sucking and oral transit in breast-fed and bottle-fed

infants. AlthoughUSprovides capabilities for observations of the feeding process in an environment thatdoes not require radiation or insertion of a scope, it has not been used extensively to date for clinical

purposes in the United States or in other parts of the world, but more for research. In general, infants and

children are referred for instrumental assessment when they are physiologically stable and when theclinical findings or history indicate possible swallowing or related abnormalities that will impact decision

making regarding oral feeding.

Interpretation of FindingsInterpretation of instrumental findings is made in conjunction with the history, clinical findings, and otherhealth-related issues. It is of interest to note that typically developing children who experience a traumatic

choking event or have pain with swallowing during an acute illness may stop eating all solid food, loseweight, and become fearful of the entire eating experience. Some gain confidence to resume normal oraleating once they have viewed the video of their swallowing during aVFSSand can see that there is

nothing blocking the movement of the food going through their pharynx and into the esophagus. If theydo not resume typical eating and drinking, additional issues are likely to need resolution through
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intervention related to psychological issues or further workup for other possible underlying physical orphysiologic problems. Examples ofVFSScases may be seen inVideos 1,2and3.

Video 1: Normal swallowing in infants (Normal Study)

This infant, nearly 5-months old, was referred for VFSS because of concernsrelated to "spitting up frequently and sounding gurgly after feeds". He was onmedication for gastroesophageal reflux. Infant was positioned semi-upright inhis typical feeding posture in a seat for a lateral view of oral, pharyngeal, and

upper esophageal phases of swallowing. The sequence of swallows in thissegment were made as he sucked on the milk bottle nipple that has been used

at home.

Note that initially this infant sucked two times before he swallowed. Withinthe first few swallows, he settled into a 1:1 suck:swallow ratio, which is the

most efficient for infants. This infant had no aspiration or nasopharyngealpenetration. As the study progressed, he had occasional laryngeal penetrationsonly to the underside of the epiglottis. He cleared the pharynx with completion

of each swallow. If this infant maintains the pattern demonstrated in thisexamination throughout feedings, there is no obvious reason that any

respiratory concerns would be directly related to his swallowing mechanism.

Video 2: Grossly abnormal swallowing in an infant. (Severe pharyngeal phase dysphagia.)

A 7-month-old infant was referred for VFSS by her primary pediatrician

because of concerns related to risks for aspiration while feeding orally. Shewas a term infant with intrauterine growth retardation. An upper GI

examination a few days prior to this examination had revealed occasionalsilent aspiration with swallowing, gastroesophageal reflux, and mild gastritis,and vomiting. She had mild developmental delays with hypertonicity.

This infant was very eager to take her bottle. This section of the VFSS shows

multiple aspiration events with the first aspiration occurring at the initiation ofthe fourth swallow. The aspiration appeared most closely correlated withtiming and coordination deficits. With increased residue in the pharynx,

particularly in the pyriform sinuses, she also aspirated as residue spilled into

the open airway following some swallows. She made no response to theaspiration, but she kept sucking eagerly. She fussed when the nipple was takenout of her mouth. Thickening liquid did not eliminate aspiration events. Shedid not aspirate with spoon feeding (not shown in this section).
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View movie file: Video 2: Grossly abnormal swallowing in an infant. (Severepharyngeal phase dysphagia.)

Video 3: Abnormal swallowing resulting in delayed aspiration. (Occasional aspiration)

This 6-month-old infant was referred for VFSS because of concerns related tovomiting during and apart from feedings as well as choking and coughingduring nipple feeds. History was significant for intrauterine drug exposure that

included cocaine and methamphetamine throughout the pregnancy. He hasbeen in foster care since the newborn period. Thickened feeds had not helped

reduce vomiting. An UGI examination 2 weeks prior to this examinationrevealed nonobstructive upper GI with gastroesophageal reflux.He was positioned for bottle feeding and lateral view with foster mother

presenting his formula with milk bottle nipple used at home. His suck-to-swallow ratio varies from 1:1 to 3:1, which is basically efficient for taking

sufficient volume to meet caloric needs. Note that when he sucks multipletimes before swallowing, the liquid is seen deeper in his pharynx (to the

pyriform sinuses) resulting in a brief delay in initiation of a pharyngeal

swallow. When that pattern is seen, one gets suspicious for potential aspirationas an infant continues to suck and swallow. Therefore it is important to

observe more than just a few swallows with bottle feeding. By the16thswallow, aspiration occurred as he was initiating a swallow. There was nocough. He continued to suck and swallow, with additional aspiration events.

Near the end of this section, the nipple was removed and you can tell that heproduced a delayed cough, but he did not clear his airway.

View movie file: Video 3: Abnormal swallowing resulting in delayedaspiration. (Occasional aspiration)

Flexible Endoscopic Examination of Swallowing (FEES)

For infants and children, a pediatric otolaryngologist and speech-language pathologist typically performtheFEEStogether as a team. Swallowing function parameters evaluated include pharyngeal pooling ofsecretions, premature spillage into pharynx, laryngeal penetration, aspiration, residue, vocal fold mobility,gag reflex, and laryngeal adductor reflex (LAR). Major disadvantages include incomplete examination of

the pharyngeal phase of swallow, lack of visualization of the oral or esophageal phases of swallowing,and thus the inability to evaluate coordination of pharyngeal motility with tongue action, laryngeal

elevation or excursion, and upper esophageal opening. When airway concerns are prominent ,FEESispreferable toVFSSto assess airway safety even prior to oral intake. FEEScan be performed at thebedside, which can be a major advantage for some infants and children. This examination requires the

child's cooperation, just as theVFSSdoes in order to have reliable and valid findings that should help toclarify the oral feeding status. This examination may be particularly useful for children with

developmental disabilities and neurologic impairments.topof page

Management of Feeding and Swallowing Problems in Pediatrics
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Management decisions are made in light of the total child with consideration for medical/surgical,nutrition, oral sensorimotor, behavioral, and psychosocial factors. Intervention strategies are focused on

primary problem areas of deficit. Evidence-based practice guidelines are needed. Airway stability andadequate nutrition/hydration status are prerequisites for all oral sensorimotor and behavioral approachesto increase the volume of oral feeding or to improve oral skills to expand food textures and to increaseefficiency. Initial efforts to improve caloric intake may include increasing caloric density of food, as per

the dietitian and physician, along with making adjustments of food textures to improve efficiency andsafety of oral feeding. Adequate fluid intake is critical to meet hydration needs and to minimize potentialof constipation, which can be a major complicating factor in facilitating hunger, appetite, and interest infeeding.Oral sensorimotor intervention involves strategies related to the function of oral structures for bolusformation and oral transit that are under voluntary neurologic control, that is, the jaw, lips, cheeks,

tongue, and palate. Techniques vary widely among therapists with little evidence of efficacy, efficiency,and outcomes. Some children appear to improve oral function when foods vary on the basis of texture,

tastes, and temperature. Other children show significantly improved oral skills and timing of swallowingwith posture and position changes. Frequently used strategies include tapping or stroking the face and

using a "Nuk " brush or other kinds of stimulation. Parents and therapists report that this kind ofstimulation will "wake up the system" and then the child will swallow more quickly and more firmly.

However, data are sorely lacking. Goals of specific exercises usually relate to improved strength andcoordination, but without defined objective measures of outcomes.Professionals and parents do not disagree about the importance of adequate nutrition/hydration. However,

there is more likely to be disagreement regarding the need for a gastrostomy tube (GT). It is not unusualfor parents to need some time, at least a few weeks or even months, before they agree to a GT. Anasogastric (NG) tube may be used for a few weeks as a test to determine if the child tolerates needed

volume of liquid per feeding time without discomfort or emesis. TheNGtube feeds also provide anopportunity to monitor weight gain. If nonoral feeds are likely to be required for longer than several

weeks, not necessarily for total oral feeding but perhaps just to meet fluid requirements or formedications, a GT should be considered. A feeding gastrostomy tube often relieves stress on thecaregivers by allowing freedom from fear of malnutrition. More efficient caloric delivery also frees time

for other more pleasurable interactions with the child. Some oral therapy should continue at appropriate

levels to ensure the continued experience and maximal development of oral skills over time. Speech-language pathologists can train parents, who can then take advantage of offering tastes during several

brief "practice" sessions each day. Duration of each session should be only about 5 to 10 minutes in thesecircumstances. When a child is on bolus feeds, optimal timing for "pleasurable practice" is likely to be

shortly before the start of the tube feeding, providing the child does not show aversive reactions to thetube feedings.Data on evidence-based research are needed. All therapeutic approaches have a primary goal for eachchild to experience healthy, safe, and pleasurable oral feeding, whether the child is a total oral feeder orgets just limited quantities and types of food for practice and pleasure. Pulmonary stability and nutritional

well-being are always the primary goals for all infants and children.

Table 1 - Gestational ages for swallowing and sucking


Joan C. Arvedson

GI Motility online (2006)

doi:10.1038/gimo17

Swallowing function Gestational age (weeks)
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Swallowing function Gestational age (weeks)

Pharyngeal swallow 1014

True suckling 1824

Tongue cupping 28

Sustain nutrition totally orally 3437

Table 2 - Five primary stages of sucking in preterm infants


Joan C. Arvedson

GI Motility online (2006)doi:10.1038/gimo17

Stage Description

Source:Adapted from Lau et al.8

1a No suction; arrhythmic expression

1b Arrhythmic alternation of suction and expression

2a No suction; rhythmic expression

2b Arrhythmic alternation of suction and expression; sucking bursts noted

3a No suction; rhythmic expression

3bRhythmic suction and expression; suction amplitude increases, wide amplitude range, prolongedsucking bursts

4 Rhythmic suction and expression; well-defined suction, amplitude range decreased

5Rhythmic, well-defined suction and expression; increasing suction amplitude; sucking patternsimilar to term infant

Table 3 - Developmental milestones and feeding skills birth to 36 months

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Age (months) Development/posture Feeding/oral sensorimotor

Using scissors cup drinking with no spilling

Using fingers to fill spoonEating wide range of solid foodTotal self-feeding, using fork

Table 4 - Feeding-related psychosocial milestones: birth to 36 months


Joan C. Arvedson

GI Motility online (2006)

doi:10.1038/gimo17

Stage Psychosocial milestones

Source:Adapted from Chatoor et al.11

Birth to 3 months Cues for feeding: arousal, cry, rooting, sucking

(homeostasis)

Caregiver responds to cues (leads to self-regulation)

Infant quiets to voiceHungersatiety pattern developsInfant smile promotes interaction with primary caregiverPleasurable feeding experiences greater environmentalinteraction

3 to 6 months (attachment)

Primary interactions"falling in love"

Reciprocity of positive infant and caregiver interactions

Consistent cuesAnticipation of feedingPauses likely socialization, not necessarily for burping or toindicate satietySmiling, laughing, social, alertPreferred feeders are parents

Calls for attention by 6 months

6 to 36 months Responds to "no"
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Stage Psychosocial milestones

(Separation/individuation) Imitates movements, and gradually imitation of speech

Play activity to explore environment (79 months)Facial expression used to indicate likes and dislikesFollows simple directionsSelf-feeding emergesMealtimes become more predictable

Speech becomes importantDirection followinggradually 23 step commandsMealtimes become part of whole family scheduleRapid increase in language 2436 monthsIndependent feeding by end of period

Table 5 - Feeding/swallowing team members and their functions


Joan C. Arvedson

GI Motility online (2006)doi:10.1038/gimo17

Team member Function

Source:Adapted from Arvedson and Brodsky10(pp. 67).

Parents Primary caregiver and decision maker for child

Physician Medical leader

(gastroenterologist, developmental pediatrician,or pediatric physiatrist)

Team co-leader

Pediatric health and neurodevelopmental diagnosisMedical and health monitoring within specialty area

Speech-language pathologist

Team co-leader (active in feeding clinic andcoordinates programmatic activities)Clinic and inpatient feeding and swallowing

evaluation

Videofluoroscopic swallow study (VFSS)(withradiologist)Flexible endoscopic examination of swallowing(FEES)(with otolaryngologist)

Oral sensorimotor intervention program

Nurse

Leads preclinic planning

Reviews records and parent informationCoordinates patient follow-up
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Team member Function

Changes gastrostomy tubes

Dietitian/nutritionistAssesses past and current dietsDetermines nutrition needs

Monitors nutrition status

Psychologist

Identifies and treats psychological and behavioral

feeding problemsGuides parents for behavior modification strategiesDirects inpatient behavioral feeding program

Occupational therapistEvaluates and treats children with problems related to

posture, tone, and sensory issues

Social workerAssists families for community resources in a varietyof ways

Acts as advocate for the child

Additional specialists

Otolaryngologist

Physical examination of upper aerodigestive tract

Detailed airway assessmentFEESwith speech-language pathologist

Medical and surgical treatment of airway problems

Pulmonologist Lower airway diseaseevaluation and management

Radiologist

VFSSwith speech-language pathologist

Computed tomography (CT)scan of chestVaried radiographic diagnostic studies

Pediatric surgeon Surgical management of gastrointestinal disease

Cardiovascular surgeon Surgical management of cardiac disease

Neurologist/neurosurgeonMedical and surgical management of neurologic

problems

Physical therapistSeating evaluations and modifications to seating

systems

References

1. Laitman J, Reidenberg J. Specializations of the human upper respiratory and upper digestivesystems as seen through comparative and developmental anatomy.Dysphagia1993;8:318325. |Article|PubMed|ChemPort|

2. Sullivan PB, Lambert B, Roe M, et al. Prevalence and severity of feeding and nutritional

problems in children with neurological impairment: Oxford feeding study.Dev Med ChildNeurol2000;42:674680. |Article|PubMed|ChemPort|

3.

Miller JL, Sonies BC, Macedonia C. Emergence of oropharyngeal, laryngeal and swallowingactivity in the developing fetal upper aerodigestive tract: an ultrasound evaluation.Early HumDev2003;71(1):6187.

4. Ross MG, Nyland MJM. Development of ingestive behavior.Am J Physiol1998;43:R879R893.5. Devries JIP, Visser GHA, Prechtl HFR. The emergence of fetal behavior: II. Quantitative

aspects.Early Hum Dev1985;12:99120. |Article|PubMed|ChemPort|

6. Bosma JF. Development of feeding. Clin Nutr1986;5:210218.
http://www.nature.com/gimo/contents/pt1/abbreviations/gimo17_abbreviations.html#df6http://www.nature.com/gimo/contents/pt1/abbreviations/gimo17_abbreviations.html#df6http://www.nature.com/gimo/contents/pt1/abbreviations/gimo17_abbreviations.html#df13http://www.nature.com/gimo/contents/pt1/abbreviations/gimo17_abbreviations.html#df13http://www.nature.com/gimo/contents/pt1/abbreviations/gimo17_abbreviations.html#df4http://www.nature.com/gimo/contents/pt1/abbreviations/gimo17_abbreviations.html#df4http://www.nature.com/gimo/contents/pt1/abbreviations/gimo17_abbreviations.html#df4http://dx.doi.org/10.1007/BF01321770http://dx.doi.org/10.1007/BF01321770http://dx.doi.org/10.1007/BF01321770http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?holding=npg&cmd=Retrieve&db=PubMed&list_uids=8269722&dopt=Abstracthttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?holding=npg&cmd=Retrieve&db=PubMed&list_uids=8269722&dopt=Abstracthttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?holding=npg&cmd=Retrieve&db=PubMed&list_uids=8269722&dopt=Abstracthttp://chemport.cas.org/cgi-bin/sdcgi?APP=ftslink&action=reflink&origin=npg&version=1.0&coi=1:STN:280:ByuD1MvlvVU%3D&pissn=%7bprintIssn%7d&pyear=2006&md5=5c5199cd26a9f014e8ee3d15daac2d88http://chemport.cas.org/cgi-bin/sdcgi?APP=ftslink&action=reflink&origin=npg&version=1.0&coi=1:STN:280:ByuD1MvlvVU%3D&pissn=%7bprintIssn%7d&pyear=2006&md5=5c5199cd26a9f014e8ee3d15daac2d88http://chemport.cas.org/cgi-bin/sdcgi?APP=ftslink&action=reflink&origin=npg&version=1.0&coi=1:STN:280:ByuD1MvlvVU%3D&pissn=%7bprintIssn%7d&pyear=2006&md5=5c5199cd26a9f014e8ee3d15daac2d88http://dx.doi.org/10.1017/S0012162200001249http://dx.doi.org/10.1017/S0012162200001249http://dx.doi.org/10.1017/S0012162200001249http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?holding=npg&cmd=Retrieve&db=PubMed&list_uids=11085295&dopt=Abstracthttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?holding=npg&cmd=Retrieve&db=PubMed&list_uids=11085295&dopt=Abstracthttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?holding=npg&cmd=Retrieve&db=PubMed&list_uids=11085295&dopt=Abstracthttp://chemport.cas.org/cgi-bin/sdcgi?APP=ftslink&action=reflink&origin=npg&version=1.0&coi=1:STN:280:DC%2BD3M%2FjsFChtg%3D%3D&pissn=%7bprintIssn%7d&pyear=2006&md5=8ae50a310fa0a735246ef433de1bfa66http://chemport.cas.org/cgi-bin/sdcgi?APP=ftslink&action=reflink&origin=npg&version=1.0&coi=1:STN:280:DC%2BD3M%2FjsFChtg%3D%3D&pissn=%7bprintIssn%7d&pyear=2006&md5=8ae50a310fa0a735246ef433de1bfa66http://chemport.cas.org/cgi-bin/sdcgi?APP=ftslink&action=reflink&origin=npg&version=1.0&coi=1:STN:280:DC%2BD3M%2FjsFChtg%3D%3D&pissn=%7bprintIssn%7d&pyear=2006&md5=8ae50a310fa0a735246ef433de1bfa66http://dx.doi.org/10.1016/0378-3782(85)90174-4http://dx.doi.org/10.1016/0378-3782(85)90174-4http://dx.doi.org/10.1016/0378-3782(85)90174-4http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?holding=npg&cmd=Retrieve&db=PubMed&list_uids=3905353&dopt=Abstracthttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?holding=npg&cmd=Retrieve&db=PubMed&list_uids=3905353&dopt=Abstracthttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?holding=npg&cmd=Retrieve&db=PubMed&list_uids=3905353&dopt=Abstracthttp://chemport.cas.org/cgi-bin/sdcgi?APP=ftslink&action=reflink&origin=npg&version=1.0&coi=1:STN:280:BimD2MrksFw%3D&pissn=%7bprintIssn%7d&pyear=2006&md5=cbf122eb88f93b11e0c43debd9c1ee30http://chemport.cas.org/cgi-bin/sdcgi?APP=ftslink&action=reflink&origin=npg&version=1.0&coi=1:STN:280:BimD2MrksFw%3D&pissn=%7bprintIssn%7d&pyear=2006&md5=cbf122eb88f93b11e0c43debd9c1ee30http://chemport.cas.org/cgi-bin/sdcgi?APP=ftslink&action=reflink&origin=npg&version=1.0&coi=1:STN:280:BimD2MrksFw%3D&pissn=%7bprintIssn%7d&pyear=2006&md5=cbf122eb88f93b11e0c43debd9c1ee30http://chemport.cas.org/cgi-bin/sdcgi?APP=ftslink&action=reflink&origin=npg&version=1.0&coi=1:STN:280:BimD2MrksFw%3D&pissn=%7bprintIssn%7d&pyear=2006&md5=cbf122eb88f93b11e0c43debd9c1ee30http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?holding=npg&cmd=Retrieve&db=PubMed&list_uids=3905353&dopt=Abstracthttp://dx.doi.org/10.1016/0378-3782(85)90174-4http://chemport.cas.org/cgi-bin/sdcgi?APP=ftslink&action=reflink&origin=npg&version=1.0&coi=1:STN:280:DC%2BD3M%2FjsFChtg%3D%3D&pissn=%7bprintIssn%7d&pyear=2006&md5=8ae50a310fa0a735246ef433de1bfa66http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?holding=npg&cmd=Retrieve&db=PubMed&list_uids=11085295&dopt=Abstracthttp://dx.doi.org/10.1017/S0012162200001249http://chemport.cas.org/cgi-bin/sdcgi?APP=ftslink&action=reflink&origin=npg&version=1.0&coi=1:STN:280:ByuD1MvlvVU%3D&pissn=%7bprintIssn%7d&pyear=2006&md5=5c5199cd26a9f014e8ee3d15daac2d88http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?holding=npg&cmd=Retrieve&db=PubMed&list_uids=8269722&dopt=Abstracthttp://dx.doi.org/10.1007/BF01321770http://www.nature.com/gimo/contents/pt1/abbreviations/gimo17_abbreviations.html#df4http://www.nature.com/gimo/contents/pt1/abbreviations/gimo17_abbreviations.html#df13http://www.nature.com/gimo/contents/pt1/abbreviations/gimo17_abbreviations.html#df6


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7. Lazebnik N, Many A. The severity of polyhydramnios, estimated fetal weight and pretermdelivery are independent risk factors for the presence of congenital malformations. Gynecol

Obstet Invest1999;48:2832. |Article|PubMed|ChemPort|8. Lau C, Alagugurusamy R, Schanler RJ, Smith EO, Schulman RJ. Characterization of the

developmental stages of sucking in preterm infants during bottle feeding. ActaPadiatr2000;89:846852. |ChemPort|

9.

Lau C, Kusnierczyk I. Quantitative evaluation of infant's nonnutritive and nutritivesucking.Dysphagia2001;16:5867. |Article|PubMed|ChemPort|

10. Arvedson JC, Brodsky L.Pediatric Swallowing and Feeding: Assessment and Management, 2nded. Albany, NY: SingularThomson Learning, 2002.

11. Chatoor I, Schaefer S, Dickson L, Egan J. Nonorganic failure to thrive: a developmentalperspective.Pediatr Ann1984;13:829843. |PubMed|ChemPort|

12. Lorenz, K.Evolution and Modification of Behavior. Chicago: University of Chicago Press, 1965.13. Illingworth RS, Lister J. The critical or sensitive period, with special reference to certain feeding

problems in infants and children.J Pediatr1964;65:840848.14.

Yamamoto T, Hirayama A. Effects of softdiet feeding on synaptic density in the hippocampus

and parietal cortex of senescenceaccelerated mice.Brain Res2001;902:255263. |Article|PubMed|ChemPort|

15.

Kennell JH, Trause MA, Klaus MH. Evidence for a sensitive period in the human mother. CibaFound Symp1975;33:87101. |PubMed|

16.

Mennella JA, Jagnow CP, Beauchamp GK. Prenatal and postnatal flavor learning by human

infants.Pediatrics2001;107:e88. |Article|PubMed|ChemPort|
http://dx.doi.org/10.1159/000010129http://dx.doi.org/10.1159/000010129http://dx.doi.org/10.1159/000010129http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?holding=npg&cmd=Retrieve&db=PubMed&list_uids=10394088&dopt=Abstracthttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?holding=npg&cmd=Retrieve&db=PubMed&list_uids=10394088&dopt=Abstracthttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?holding=npg&cmd=Retrieve&db=PubMed&list_uids=10394088&dopt=Abstracthttp://chemport.cas.org/cgi-bin/sdcgi?APP=ftslink&action=reflink&origin=npg&version=1.0&coi=1:STN:280:DyaK1Mzitl2jsQ%3D%3D&pissn=%7bprintIssn%7d&pyear=2006&md5=5f5cd0f1b9270c4efe6b98fca750a682http://chemport.cas.org/cgi-bin/sdcgi?APP=ftslink&action=reflink&origin=npg&version=1.0&coi=1:STN:280:DyaK1Mzitl2jsQ%3D%3D&pissn=%7bprintIssn%7d&pyear=2006&md5=5f5cd0f1b9270c4efe6b98fca750a682http://chemport.cas.org/cgi-bin/sdcgi?APP=ftslink&action=reflink&origin=npg&version=1.0&coi=1:STN:280:DyaK1Mzitl2jsQ%3D%3D&pissn=%7bprintIssn%7d&pyear=2006&md5=5f5cd0f1b9270c4efe6b98fca750a682http://chemport.cas.org/cgi-bin/sdcgi?APP=ftslink&action=reflink&origin=npg&version=1.0&coi=1:STN:280:DC%2BD3Mzgt1Gitw%3D%3D&pissn=%7bprintIssn%7d&pyear=2006&md5=f798226789a45208e513582887991e4dhttp://chemport.cas.org/cgi-bin/sdcgi?APP=ftslink&action=reflink&origin=npg&version=1.0&coi=1:STN:280:DC%2BD3Mzgt1Gitw%3D%3D&pissn=%7bprintIssn%7d&pyear=2006&md5=f798226789a45208e513582887991e4dhttp://chemport.cas.org/cgi-bin/sdcgi?APP=ftslink&action=reflink&origin=npg&version=1.0&coi=1:STN:280:DC%2BD3Mzgt1Gitw%3D%3D&pissn=%7bprintIssn%7d&pyear=2006&md5=f798226789a45208e513582887991e4dhttp://dx.doi.org/10.1007/s004550000043http://dx.doi.org/10.1007/s004550000043http://dx.doi.org/10.1007/s004550000043http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?holding=npg&cmd=Retrieve&db=PubMed&list_uids=11213247&dopt=Abstracthttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?holding=npg&cmd=Retrieve&db=PubMed&list_uids=11213247&dopt=Abstracthttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?holding=npg&cmd=Retrieve&db=PubMed&list_uids=11213247&dopt=Abstracthttp://chemport.cas.org/cgi-bin/sdcgi?APP=ftslink&action=reflink&origin=npg&version=1.0&coi=1:STN:280:DC%2BD3M7ktFyisA%3D%3D&pissn=%7bprintIssn%7d&pyear=2006&md5=157da1584b4abb336c6f5fbea05d51fchttp://chemport.cas.org/cgi-bin/sdcgi?APP=ftslink&action=reflink&origin=npg&version=1.0&coi=1:STN:280:DC%2BD3M7ktFyisA%3D%3D&pissn=%7bprintIssn%7d&pyear=2006&md5=157da1584b4abb336c6f5fbea05d51fchttp://chemport.cas.org/cgi-bin/sdcgi?APP=ftslink&action=reflink&origin=npg&version=1.0&coi=1:STN:280:DC%2BD3M7ktFyisA%3D%3D&pissn=%7bprintIssn%7d&pyear=2006&md5=157da1584b4abb336c6f5fbea05d51fchttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?holding=npg&cmd=Retrieve&db=PubMed&list_uids=6595632&dopt=Abstracthttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?hold

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