Conceptual Framework and Definitions
Consensus Definition: Eating
Eating is the ability to keep and manipulate food or fluid in the mouth and swallow it (Alberta College of Occupational Therapy, 2009).
Consensus Definition: Feeding
From an occupational performance perspective, feeding is the process of setting up, arranging and bringing food to the mouth. It is sometimes referenced as self-feeding (Alberta College of Occupational Therapy, 2009); (American Occupational Therapy Association, 2014b). From anatomical and physiological perspectives, “feeding is the process involving any aspect of eating or drinking, including gathering and preparing food and liquid for intake, sucking or chewing, and swallowing”. (Arvedson & Brodsky, 2002); (American Speech-Language-Hearing Association, 2019).
In the pediatric population, feeding is embedded in the relationship between an infant, child or youth, and a parent or caregiver. Feeding provides children and their parents or caregivers with opportunities to communicate and interact with each other to create a positive social experience that informs future interactions (Lefton-Greif M., 2008). Children benefit from a responsive feeding environment (Black & Aboud, 2011) where the parent responds to the child’s actions in a prompt, emotionally supportive, developmentally appropriate manner (Canadian Paediatric Society, Dietitians of Canada, Health Canada & Breastfeeding Committee for Canada, 2015).
Consensus Definition: Swallowing
From an occupational performance perspective, swallowing is moving food, fluid, medication or saliva from the mouth through the pharynx and esophagus into the stomach (Alberta College of Occupational Therapy, 2009); (American Occupational Therapy Association, 2014b).
From an anatomical and physiological perspective, “swallowing is a complex process during which saliva, liquids, and foods are transported from the mouth into the stomach while keeping the airway protected. Swallowing is commonly divided into the following four phases:
- Oral Preparatory—voluntary phase during which food or liquid is manipulated in the mouth to form a cohesive bolus—includes sucking liquids, manipulating soft boluses, and chewing solid food.
- Oral Transit—voluntary phase that begins with the posterior propulsion of the bolus by the tongue and ends with initiation of the pharyngeal swallow.
- Pharyngeal—begins with the initiation of a voluntary pharyngeal swallow which in turn propels the bolus through the pharynx via involuntary peristaltic contraction of the pharyngeal constrictors.
- Esophageal—“involuntary phase during which the bolus is carried to the stomach through the process of esophageal peristalsis” (Arvedson & Brodsky, Pediatric swallowing and feeding: Assessment and management, 2002); (Logemann J. , 1998); (American Speech-Language-Hearing Association, 2019).
Consensus Definition: Pediatric Feeding Disorder
Pediatric Feeding Disorder (PFD) is defined as impaired oral intake that is not age-appropriate, lasting at least two weeks, and associated with one or more disturbance of: medical, nutritional, feeding skill, and/or psychosocial function, and the absence of the cognitive processes consistent with eating disorders and pattern of oral intake that is not due to a lack of food or congruent with cultural norms (Goday, et al., 2019).
Diagnostic Criteria: Pediatric Feeding Disorder
- A disturbance in oral intake of nutrients, inappropriate for age, lasting at least two weeks and associated with one or more of the following:
- Medical dysfunction, as evidenced by any of the following:
- cardiorespiratory compromise during oral feeding
- aspiration or recurrent aspiration pneumonitis
- Nutritional dysfunction, as evidenced by any of the following:
- specific nutrient deficiency or significantly restricted intake of one or more nutrients resulting from decreased diet diversity
- reliance on enteral feeds or oral supplements to sustain nutrition and/or hydration
- Feeding skill dysfunction, as evidenced by any of the following:
- need for texture modification of liquid or food
- use of modified feeding position or equipment
- use of modified feeding strategies
- Psychosocial dysfunction, as evidenced by any of the following
- active or passive avoidance behaviours by child when feeding or being fed
- inappropriate parent or caregiver management of child’s feeding and, or nutrition needs
- disruption of social functioning within a feeding context
- disruption of parent-child relationship associated with feeding
- Medical dysfunction, as evidenced by any of the following:
- Absence of the cognitive processes consistent with eating disorders and pattern of oral intake that is not due to a lack of food or congruent with cultural norms (Goday, et al., 2019).
Consensus Definition: Pediatric Swallowing (Dysphagia) Disorder
Dysphagia is the term used to refer to a disruption, impairment, or disorder of the process of deglutition (the action or process of swallowing) that compromises the safety, efficiency, or adequacy of the oral intake of nutrients (Dodrill & Gosa, Pediatric Dysphagia: Physiology, Assessment, and Management, 2015); (Alberta College of Speech-Language Pathologists and Audiologists, 2013). Dysphagia may involve the oral cavity, pharynx, or esophagus, and affect the oral, pharyngeal, and/or esophageal phases of swallowing (American Speech-Language-Hearing Association, 2019). It affects an infant, child, or youth’s ability to safely suck, drink, chew, eat, control saliva, take medication, or protect the airway.
Dysphagia is a skill-based disorder not to be confused with a behaviourally based feeding disorder. It can occur at any time during the lifespan and may be short or extended in duration. Dysphagia is not a disease but rather a symptom or secondary consequence of an underlying neurogenic, oncologic, structural, psychogenic, surgical, congenital, or iatrogenic pathology (Alberta College of Speech-Language Pathologists and Audiologists, 2013). The most common causes of dysphagia are related to underlying medical or physical conditions. However, it is recognized that dysphagia can also manifest in psychological or psychiatric conditions (Vaiman, Shoval, & Gavriel, 2008).
Diagnostic Criteria: Pediatric Swallowing (Dysphagia) Disorder
Pediatric Swallowing Disorder, or dysphagia, is defined as compromised airway (e.g. laryngeal, tracheal, and/or bronchial) protection, aspiration, or laryngeal penetration in one or more of the four phases of swallowing: oral, oropharyngeal, pharyngeal, and/or pharyngoesophageal (American Speech-Language-Hearing Association, 2019); (Alberta College of Speech-Language Pathologists and Audiologists, 2013). Diagnosis includes description of the nature and severity of impairment.
A clinical feeding evaluation does not reliably diagnose oropharyngeal dysphagia and aspiration (Duncan, Mitchell, Larson, & Rosen, 2018). Presenting symptoms, including coughing, choking, wet voice, wet breathing, tearing or red eyes, or changes in colour with feeding, do not reliably predict aspiration risk in children. For children at high risk for aspiration, instrumental evaluations of swallowing are recommended. (Duncan, Mitchell, Larson, & Rosen, 2018).