When to see a feeding therapist

Feeding therapy, and who does it

Feeding therapy helps children who find eating or drinking hard, whether that’s managing food safely in the mouth and throat, moving on to new textures, or coping with eating at all.

The AAP says feeding therapy is provided by trained specialists, often speech-language pathologists or occupational therapists. In the UK, speech-language pathologists are called speech and language therapists.

• Speech-language pathologists work on sucking, chewing and swallowing, including whether food or drink is going the wrong way (ASHA).
• Occupational therapists can help with everyday skills such as self-feeding (Hertfordshire Community NHS Trust).
• They may work in a feeding team with a doctor or nurse, a registered dietitian, a psychologist or other specialists (ASHA).

Many feeding struggles are a normal stage

Most babies and toddlers have some trouble while they learn. ASHA says all children may spill liquids, push food back out, or gag when trying new foods, and that some of this is typical and should go away over time. The difference with a feeding or swallowing disorder is that the problems keep going.

If you’re not sure yet, these guides cover the common, normal stages: gagging vs choking, introducing textures, why is my baby refusing food? and picky eating in toddlers.

It’s not about something you did

Asking for help doesn’t mean you’ve done something wrong. ASHA says feeding and swallowing problems usually happen because of other medical conditions, and sometimes for no known reason. Possible causes include reflux, being born early or with a low birth weight, heart or breathing problems, cleft lip or palate, muscle weakness, autism, and sensory issues with textures, colors, smells and tastes.

Feeding therapy works with you: ASHA says the team suggests ways to help, which often include new ways for you to support your child at meals.

Signs it’s worth asking about a feeding therapist

Talk to your pediatrician, GP or health visitor if your child:

• often coughs, gags or chokes during meals or drinks (ASHA)
• keeps gagging on textures long after the early weeks of solids: see introducing textures
• refuses most solid foods after 9 months of age, or a feeding problem happens often or doesn’t get better (AAP)
• isn’t gaining weight or growing as expected, or is losing weight (AAP, ASHA)
• eats only a very small range of foods, or only certain textures, such as only soft or only crunchy food (ASHA, NHS inform)
• takes a very long time to eat, or often pockets food in the cheeks (ASHA): see pocketing food
• falls asleep or fusses at most feeds, or spits up or throws up a lot (ASHA)
• seems anxious or very upset at mealtimes, or mealtimes have become very stressful for the family (NHS inform, ASHA)
• has become afraid to eat after a choking or vomiting scare (NHS inform)

NHS inform explains that avoidant restrictive food intake disorder (ARFID) is more than picky eating: it’s when restricting food has a negative effect on health, such as not gaining weight as expected, low iron, or anxiety about eating that affects daily life. For young people, treatment may come through community children’s services, including speech and language therapy, occupational therapy and dietetics.

Signs food may be going the wrong way: see the doctor soon

When food or drink goes into the airway (aspiration), it can cause pneumonia or other lung infections (ASHA). Don’t wait for a therapy appointment if your child:

• coughs or chokes while eating or drinking, again and again
• has a wet, gurgly, hoarse or breathy voice during or after eating
• has breathing that sounds wet or noisy while eating, but settles afterward
• brings food or milk back up through the nose
• keeps getting chest infections
• cries a lot or arches their back when feeding (NHS)

Call your pediatrician or GP and ask to be seen soon. The NHS says to ask for an urgent GP appointment or call NHS 111 for these signs (NHS). If breathing is hard, don’t wait for an appointment: use the emergency steps below.

If your child can’t breathe, cough or cry, they may be choking: start choking first aid straight away. Shout for help and have someone call 911 straight away. If you’re alone and your phone is with you, put it on speaker, call, and start back blows at once. Don’t leave your child to find a phone.Shout for help and start back blows and thrusts straight away. If someone is with you, ask them to call 999 now. If you’re alone, call 999 (on speaker) if the blockage hasn’t cleared after one round of back blows and thrusts, and keep going until help arrives.Shout for help and have someone call your local emergency number (such as 112 in Europe or 000 in Australia) straight away. If you’re alone and your phone is with you, put it on speaker, call, and start back blows at once.

Call 911 or go to the emergency room if your child is struggling to breathe, short of breath, wheezing, breathing very fast, or turning blue, gray or pale.Call 999 or go to A&E if your child is struggling to breathe, short of breath, wheezing, breathing very fast, or turning blue, grey or pale (NHS).Call your local emergency number (such as 112 in Europe or 000 in Australia) or go to the emergency department if your child is struggling to breathe, short of breath, wheezing, breathing very fast, or turning blue, gray or pale.

What happens at an evaluation

ASHA describes what a feeding specialist usually does:

• asks about your child’s health, development and what you’ve noticed
• watches how your child moves their mouth and tongue
• watches them eat and drink, and how they behave at meals

If swallowing is a worry, they may suggest a test that shows where food goes, such as a modified barium swallow (an X-ray while your child eats or drinks) or a FEES (a small camera passed through the nose). Some UK services ask for short videos of your child eating at home (Kent).

Therapy then depends on your child. It may mean changing textures or how thick drinks are, trying a different seating position, gentle steps toward new foods, help with sensory issues, or treatment for a medical cause such as reflux (ASHA).

How to get a referral

In the US, start with your pediatrician, who can check growth and refer you to a feeding specialist. ASHA also has a ProFind directory of certified speech-language pathologists. If your child is under 3, you can also call your state’s early intervention program yourself and ask for an evaluation: the CDC says a doctor’s referral isn’t necessary, services can include speech therapy, and they’re free or at reduced cost for eligible children. From age 3, the CDC says to call a local public elementary school.In the UK, your health visitor or GP is usually the place to start. Some children’s speech and language therapy services accept contact from parents, such as Kent’s feeding and swallowing service, while others, such as Hertfordshire’s, take eating and swallowing referrals only from a health professional. Services also differ on what they accept: Kent’s service, for example, doesn’t take referrals for restricted eating alone or for difficulties starting solids, and points families to their health visitor or GP. Your health visitor or GP will know which local service covers your child’s problem.Start with your child’s doctor or child health nurse, who can check growth and refer you to a feeding specialist, such as a speech therapist or occupational therapist.

Bring notes to the appointment: what your child eats in a typical day, which foods or textures cause trouble, and any coughing, gagging or vomiting. A short video of a meal can help too.

While you wait

• Keep mealtimes calm, with no pressure or bribes: see picky eating in toddlers.
• Keep offering foods your child manages well, in safe sizes: see safe food sizes and shapes.
• Sit your child upright and stay with them while they eat.
• If you’re worried about how much your baby is eating, see is my baby eating enough?.

Where US and UK advice differs

• The job title. In the US, a speech-language pathologist (SLP); in the UK, a speech and language therapist (SLT). Both do the same feeding and swallowing work.
• The route in. In the US, your pediatrician refers you, and families can also contact early intervention directly for children under 3 (CDC). In the UK, the GP or health visitor usually refers, and local NHS services set their own rules on who can refer.
• Urgent swallowing worries. The NHS points families to an urgent GP appointment or NHS 111. US sources (ASHA) say to talk to your child’s doctor: call your pediatrician’s office and describe the signs, so they can decide how soon your child needs to be seen.