Feeding Assessment: 5 Key Questions

To guide a thorough feeding assessment, answer the following 5 Key Questions and consider the four health domains (i.e. Medical, Nutrition & Hydration, Feeding Skill, and Psychosocial) within each question

  1. Is the current method of feeding safe?
  2. Is the feeding adequate?
  3. Is feeding a positive experience for child and parent?
  4. Is feeding appropriate for child’s developmental capacity?
  5. Is feeding efficient?

The questions included in this assessment are listed in order of priority to identify, diagnose, and address feeding problems. The questions and considerations included are aimed at supporting a thorough feeding assessment, rather than being used as a checklist. Clinicians should complete the assessment considering the child and family context, and their individual scope of practice. See below for more detailed considerations for each question and each domain.

Clinicians need to identify areas for management based on the combined results of the feeding assessment framework, rather than isolated issues from individual questions.

Ensure you have a complete history including diagnosis and medication list, physical exam, anthropometrics, nutrition assessment, medical and behavioural signs and symptoms, basic laboratory evaluation, and early referral to interdisciplinary teams (Kerzner, et al., 2015).

There exist several published assessment tools designed to evaluate one or more of the 5 Key Questions that guide a thorough feeding assessment. Many of these assessments describe their psychometric properties (validity and reliability of the measurement tool) in their respective technical manuals. The psychometric evidence of many assessments is either inadequate or inconsistent, with limited information on the validity and reliability of these assessments. Therefore most assessment tools should be used with caution (Speyer, Cordier, Parsons, Denman, & Kim, 2018); (Heckathorn, Speyer, Taylor, & Cordier, 2016); (Barton, Bickell, & Fuciles, 2018). 
The following validated tools are designed to evaluate one or more of the 5 Key Questions that guide a thorough feeding assessment:

  • Neonatal Eating Assessment Tool (NeoEAT)  (Pados, Estrem, Thoyre, Park, & McComish, 2017)
  • Pediatric version of the Eating Assessment Tool (PEDI-EAT-10) (Belafsky, 2008) (Thoyre, et al., 2017)
  • Behavioral Pediatric Feeding Assessment Scale (BPFAS) (Crist & Napier-Phillips, 2001)
  • Feeding/Swallowing Impact Survey (FS-IS) (Lefton-Greif, et al., 2014)
  • Montreal Children’s Hospital Feeding Scale: A brief bilingual screening tool for identifying feeding problems (Ramsay, Martel, Porporino, & Zygmuntowicz, 2011).

PEAS neither recommends nor discommends any of these validated tools. The feeding assessment process developed by NSW Office of Kids and Families was adapted and adopted in this guide.

Question 1: Is the Current Method of Feeding Safe?

Is swallowing safe? Are there reported or observed indications of the child not tolerating the current method of (oral and/or tube) feeding? To determine if feeding is safe, consider the following within each of the domains:

Medical Domain
  • signs of aspiration or dysphagia
  • disorders that affect oral, nasal, or pharyngeal function
  • aerodigestive disease (known airway, pulmonary, gastrointestinal conditions)
  • congenital and other heart diseases
  • endurance
  • respiratory control; increased work of breathing
  • neurological status and neurodevelopmental disorders, e.g. seizures
  • gestational age and adjusted age
  • level of alertness
  • allergies
  • oral and dental hygiene
  • medication

 

Nutrition & Hydration Domain
  • food or nutrition-related history
  • food, formula (oral or enteral) and nutrient intake
  • fluid intake and hydration
  • safe preparation of texture modified diets and fluids
  • appropriate administration of enteral feeds
  • supplement use

           

Feeding Skill Domain
  • oral mechanism: structure, sensation, cranial nerve involvement 
  • oral motor and pharyngeal functioning: range of motion, strength, tone, coordination, secretion management
  • neurological and neurodevelopmental status: tone, joint stability and limitations, reflexes (including oral)
  • general development: motor and postural control, communication, cognition, state
  • positioning of child during feeding

 

Psychosocial Domain
  • parent/caregiver responsiveness, e.g. not force feeding
  • parent-child relationship
  • parent/caregiver stress and/or mental health
  • child trauma: history and current status
  • family unable to engage in assessment
  • differences across feeding environments, e.g. home, childcare, school

Question 2: Is Feeding Adequate?

Are growth and nutritional intake appropriate for age and medical condition? To determine if feeding is adequate, consider the following within each of the domains:

Medical Domain
  • excessive loss from vomiting, stool or urine
  • malabsorption
  • endurance
  • respiratory control; Increased work of breathing
  • drug-nutrient interaction: medication
  • oral hygiene or care
  • laboratory investigations

 

Nutrition & Hydration Domain

If there are acute concerns regarding hydration status, refer to a physician immediately. Signs or symptoms of dehydration may include reduced urine output, dry mucous membranes, abnormal respiratory pattern, lethargy, reduced skin turgor and sunken eyes.

 

  • growth pattern
  • intake of food, formula, fluid, and nutrients (oral or enteral)
  • nutrient deficiency or toxicity
  • hydration
  • supplement use
  • appetite
  • urine and stool output
  • diet restrictions (prescribed or child or parent initiated) and limited food repertoire

 

Feeding Skill Domain
  • oral motor skills to manage textures and consistencies
  • neurodevelopmental and general developmental factors
  • endurance
  • range of food that is appropriate for the child’s developmental capacity

               

Psychosocial Domain
  • child’s ability to communicate hunger or satiety cues
  • cultural or social expectations of growth
  • environment: grazing, lack of routine
  • child’s sensory preferences and sensitivities

Question 3: Is Feeding a Positive Experience for Child and Parent?

Is feeding is a positive experience? Are there challenges in the relationship between child and parent that affect the mealtime experience? Are there broader relationship challenges between child and parent evident during non-mealtime interactions? To determine if feeding is a positive experience, consider the following within each of the domains:

Medical Domain
  • parent/caregiver and child mental health diagnoses
  • sleep patterns for parent and child
  • child pain or discomfort related to a medical condition

 

Nutrition & Hydration Domain
  • food over-selectivity
  • child’s response to being tube fed
  • hydration inadequacy

 

Feeding Skill Domain
  • failure to advance to age appropriate diet despite adequate skill
  • child’s communication abilities: receptive, expressive
  • child’s sensory preferences and sensitivities
  • parent knowledge and understanding of child’s developmental strengths, challenges, and preferences

 

Psychosocial Domain
  • feeding roles: division of responsibility 
  • feeding relationship
  • feeding environment (sensory and physical environment)
  • parent/caregiver responsiveness: ability to self-regulate and co-regulate 
  • parent social and emotional state and coping strategies
  • parent social-cultural beliefs
  • parent social, emotional and economical resources
  • child and parent learned experiences
  • child and parent readiness for change
  • child’s social-emotional state and abilities: self-regulation of stress and emotion, history of trauma, mental health

 

Indicators That a Parent May Be Experiencing Mental Health Challenges

If any of the following, or any other serious mental health challenges are observed, recommend following up with a physician, psychologist, psychiatrist, or other mental healthcare professional for consultation or advice on management:

 

  • Severe anxiety: excessive reassurance seeking (including seeking multiple professional opinions), asking the same questions repeatedly, disproportionate focus on one aspect of feeding, e.g. weight, overestimating cost or likelihood of a poor outcome, reports of feeling restless, anxious, worried. 
  • Depression (including post-natal depression): presenting with flat affect or tearfulness, reports of feeling sad, empty, hopeless or excessive guilt, difficulties concentrating, making decisions or problem-solving, difficulties enjoying interactions with child.

Question 4: Is Feeding Appropriate for the Child’s Developmental Capacity?

What is the child’s developmental stage across major domains of development, e.g. social-emotional, physical, language, and cognitive? Is the child’s developmental age and ability taken into account during feeding? To determine if feeding is appropriate for the child’s developmental capacity, consider the following within each of the domains:

Medical Domain
  • neurodevelopmental delay or disorder diagnoses
  • developmental disorder diagnoses

                                

Nutrition & Hydration Domain
  • nutrition requirements related to a medical disorder
  • range of foods, fluids and textures offered vs eaten – is there a mismatch between skill and food or drinks offered?

 

Feeding Skill Domain
  • general development: cognitive, motor, communication, social-emotional
  • exposure to feeding that is appropriate for the child’s developmental capacity
  • consistency modifications required
  • self-feeding ability – food and fluid
  • feeding environment -- positioning, where seated (orally fed/tube-fed), e.g. lap, stroller, high chair
  • time engaged in feeding

 

Psychosocial Domain
  • cultural feeding practices: opportunities for self-feeding
  • opportunity to get messy/explore food
  • mismatch between parental understanding and child’s current developmental skill level and abilities

Question 5: Is Feeding Efficient?

Are nutrition requirements being provided in a reasonable, sustainable, achievable timeframe? To determine if feeding is efficient, consider the following within each of the domains:

Medical Domain
  • impact of medications on feeding regimen (timing, frequency, alertness)
  • medications causing excessive sleepiness
  • recurrent illness – interfering with meeting targets

 

Nutrition & Hydration Domain
  • volume of food or fluid required in relation to skills for efficient intake
  • volume of enteral feeds in relation to tolerance
  • appetite
  • parent expectation and child’s ability in relation to nutrition requirements

 

Feeding Skill Domain
  • timing, pacing and duration of meals/feeds
  • learned experiences, e.g. pain associated with feeding
  • sensory experiences, e.g. food smell, taste, texture, and temperature
  • self-feeding vs assisted feeding (and skill of each)
  • consistency modifications required
  • feeding equipment, e.g. nipple flow rate, cup
  • positioning to support gross motor skills

 

Psychosocial Domain
  • eating or feeding in various settings, e.g. school
  • routine and structure
  • caregiver responsiveness and relationship to facilitate efficient eating