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Infant Feeding Difficulties: Diagnostic & Therapeutic Interventions

Author Dana Schmitz covers Infant Feeding Difficulties: Diagnostic & Therapeutic Interventions on BackTable ENT

Dana Schmitz • Aug 30, 2023 • 32 hits

Evaluating infant feeding difficulties requires precise diagnostic decisions. Flexible endoscopic evaluation of swallowing (FEES) and video fluoroscopic swallow studies are the two most common diagnostic methods for infant feeding difficulties. While these two diagnostic tools are distinct and not interchangeable, they may complement each other. Each tool has its benefits and its limitations, and providers should consider urgency, weight gain patterns, feeding method, and respiratory history before choosing a tool. It's essential to recognize that a significant proportion of typically developing children also face feeding issues, and may have no obvious underlying cause. Neuromuscular electrical stimulation (NMES) emerges as a potential therapy for pediatric dysphagia. However, its pediatric application mandates careful discernment, often relying on diagnostic aids like video swallow studies or FEES, to pinpoint the muscle groups in need. While NMES offers promise, its role in pediatric care demands more research for conclusive endorsement.

This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.

The BackTable ENT Brief

• Between 25% and 45% of normally developing children may experience feeding difficulties, according to studies cited by Ashley Brown.

• One diagnostic tool, FEES, is ideal for breastfed infants as it can be used while they are actively feeding at the breast. It is also preferred for secretion management evaluations, as it can assess for secretion aspiration and post-swallow residual. The downside of this method is that it focuses on the pharyngeal and laryngeal space, missing the oral and esophageal components.

• Another diagnostic tool, the video fluoroscopic swallow study, is preferred for infants who may need potential flow rate or consistency adjustments. It provides a comprehensive view, capturing both the oral and esophageal components of swallowing.

• FEES and the videofluoroscopic swallow study are not interchangeable, and the diagnostic tool used should align with the specific needs and concerns of each infant.

• Prolonged intubation can affect oral structure, leading to challenges like oral sensitivity and palate shape alterations.

• Neuromuscular Electrical Stimulation (NMES) is utilized to induce muscle contractions, impacting surface sensory. Video swallow studies or FEES are often used to guide electrode placement for targeting specific muscle groups. The therapy's efficacy relies on understanding the pathophysiology of the swallowing deficit.

Infant Feeding Difficulties: Diagnostic & Therapeutic Interventions

Table of Contents

(1) Flexible Endoscopic Evaluation of Swallowing (FEES) vs Video Fluoroscopy in Evaluating Infant Swallowing

(2) Key Differentiators in Infants with Feeding Difficulties

(3) Neuromuscular Electrical Stimulation in Infants with Feeding Difficulties: Indications & Implementation

Flexible Endoscopic Evaluation of Swallowing (FEES) vs Video Fluoroscopy in Evaluating Infant Swallowing

When evaluating infants with feeding difficulties, clinicians are often faced with the challenge of selecting the right diagnostic tool. In many cases, the choice revolves around FEES (Flexible Endoscopic Evaluation of Swallowing) and video fluoroscopy. FEES stands out particularly for infants who strictly breastfeed, given its unique capability to evaluate swallowing while breastfeeding. Studies underscore that breastfeeding patterns may differ from bottle feeding, highlighting the importance of appropriate evaluation methods. Additionally, FEES proves instrumental in assessing secretion management, evaluating aspiration of secretions, and observing residue post-swallow, especially in specific pediatric populations or those with head and neck concerns. On the other hand, video fluoroscopy provides comprehensive insights, especially when assessing flow rates and consistencies or when both oral and esophageal components need observation.

[Dr. Gopi Shah]
When you say instrumental, are you saying video swallow FEES, what are we talking about?

[Ashley Brown]
Yes, so we can do either. With breastfeeding babies, FEES is really, if they are strictly breastfeeding, FEES which is flexible endoscopic evaluation of swallowing, is really our go-to option if they are strictly breastfeeding neonate infant, because we cannot observe breastfeeding during a video fluoroscopic swallow study. Just because they breastfeed does not mean that they will immediately go onto a bottle and do a fluoro. We have gotten referrals for strictly breastfeeding babies, they come in for a video fluoroscopic swallow study, and they want nothing to do with the bottle. Fees is a good option for those strictly breastfeeding babies.

When it comes to the video fluoroscopic swallow study, if they are full bottle feeders, and we're really thinking we'll need to change a lot about flow rate, possibly the viscosity, the consistency, thickening the feed, and we'll maybe have to play around a lot. Fluoro sometimes is our good option there, because there's only so long someone will tolerate a scope in their nose. We can observe a full feed with the FEES because we don't have the constraints of radiation, but there is a certain tolerance level there for sure.

[Dr. Gopi Shah]
As the referring physicians, should we be ordering a video swallow before we send them to you? Should they all, like who should get imaging or workup before they're sent to you, and who should it, and what do you want?

[Ashley Brown]
That can be a little tricky, as I'm sure you know, to figure out. Does this baby need to go for a bedside outpatient evaluation, or does this seem urgent enough that we need a swallow study within the next two days? Maybe some of those clues would be if they really are not gaining weight, they are failing to thrive. We're trying to change the language around that, because saying failure to thrive puts the label on the parents that they're failing to do their job, so we're changing the language around that, but that's the most common way people know it right now.

If there is some sort of respiratory history, that maybe they've been to the ED a few times because baby is having apneic moments, or their breathing isn't right, they've turned colors, maybe we need to do an urgent swallow study at that time. If baby is maybe just a little bit messy when they're eating, they have some reflux type signs, frequent spitting up, vomiting after every feed, then maybe we don't need to go straight to fluoro, and maybe need to think about referrals to some of our other colleagues.

[Dr. Gopi Shah]
Let's get into the instrumentals. I guess first, if you could just explain that when you like a video and when do you prefer a FEES, and which ones, I guess, show you what?

[Ashley Brown]
We'll start with FEES, the flexible endoscopic evaluation of swallowing. I've already mentioned that for strictly breastfeeding babies, that is our good option. We do breastfeeding FEES in office. We've done them over in our acute care side, so that is good because we can get baby on breast, we can scope them, watch them swallow while breastfeeding, because breastfeeding is very different than bottle feeding. There have been a study showing that even though they might aspirate during a bottle feed, they don't necessarily aspirate during breastfeeding. Baby has a little more control when they are breastfeeding than bottle feeding.

That's a good option before we start, especially thinking, let's start taking PO away from this baby. I like FEES for our secretion management kids. If we are concerned that maybe this child baby is in PO, but we feel like they're not managing their secretions, FEES is really the only option and is the best option to look at, do they have copious pharyngeal secretions? Are they aspirating these secretions and not initiating a cough response to help clear those secretions? We know and we've seen from studies that have been put out fairly recently how detrimental aspirating secretions is on lung health.

It seems that it is worse than aspirating food and liquid, if you think about how nasty our mouths are, and aspirating those secretions that have mixed with maybe some bacteria in your mouth. I like the FEES for our kids that are in PO. Maybe they only do a few flavor taste, but we really want to expand on what they can do orally. Maybe give them a therapy plan of they can do a few taste of liquid or puree. I feel like those are good FEES options. I also really like, we don't encounter this as much in pediatrics, especially infant. Our head and neck cancer patients that have had a lot of radiation to that area, do we need to expose them more, you know, with a video fluoro?

FEES would be a good option because often those children, infants who-- and we've had had a few infants who have had some head and neck masses that we have had to take care of, you get a better picture of residue with Fees. Is it unilateral? Is it bilateral? How much is it? You get a better idea of how much residue there is. I like FEES for those patients as well, but FEES is also complementary to video fluoro and vice versa. Video fluoro is complementary to FEES. They don't necessarily are meant to be done alone and one is better than the other.

For our video fluoro, which is where most of our kids would fall, like I've mentioned, if we think we're really going to have to play around with flow rate, consistency, video fluoro really gives us a good picture. They did better if I paced them this many times. Also, with video fluoro, you're getting the full oral picture and esophageal. With FEES, you're only seeing that pharyngeal and laryngeal space, so you are missing the oral and esophageal component.

Listen to the Full Podcast

Feeding Difficulties in Infants with Ashley Brown, SLP on the BackTable ENT Podcast)
Ep 48 Feeding Difficulties in Infants with Ashley Brown, SLP
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Key Differentiators in Infants with Feeding Difficulties

A significant percentage of typically developing children, around 25-45% according to some research and numbers, experience feeding difficulties. These patients sometimes give no clues as to the underlying cause and it may be difficult to figure out their differential. There are multiple differentials to consider, including the impact of prolonged intubation on oral structure and sensitivity, cardiac histories, and specific syndromic presentations like trisomy 21 and 22Q11.2 deletion syndrome. Particularly pertinent is vocal cord immobility after cardiac surgeries and the increasing diagnosis of laryngeal cleft, which is being assessed more often in recent years.

[Dr. Gopi Shah]
When you're seeing these kids, in your mind, what's your differentials that are like the common dysphagia or things that you're thinking of?

[Ashley Brown]
If you look at some of the research and numbers, anywhere from like 25% to 45% of normally developing children and infants will have some sort of feeding difficulty that is a large number. I'm sure y'all can tell that from your practice that is a large number because it's every day, all day. Sometimes they don't give you any clues as to what is going on and there are these seemingly normal aspirators, and we can't quite figure out a differential there, which is very frustrating. If we think about the most common big picture that we're looking at, oral structure, tongue tie, one of them that we'll start with that's very popular right now to talk about, tone, have they had a HIE, a brain bleed?

Were they born premature? Were they intubated for a long time? What kind of clues could prolong intubation give you? Oral sensitivity being one of them. They were in the hospital for a long time, lots of things taped to their face. You can understand why they don't necessarily want to eat or a bottle coming at their face or is the therapist trying to do exercises with them. They can be very orally defensive. Intubation tube sitting in their mouth for a long time too, affects the shape of the palate, which can affect bottle feeding, not getting that great seal that you need. Are they a cardiac baby? Do they have a cardiac history? Have they had cardiac surgery?

When we think about our cardiac babies, they have a very low kind of energy reserve. Feeding is already an aerobic exercise, and then for our cardiac babies, that especially is true. Maybe they don't want to eat for longer than five minutes, and then when also you're thinking about cardiac history, is there some immobile vocal cord involvement because there was injury to the recurrent laryngeal nerve, which we see often. That is probably primarily what our voice clinic is, is children who have had a history of cardiac surgeries, PDA, ligation.

We're looking at vocal cord immobility. In general, do they have a history of syndrome? You start looking up those syndromes, trisomy 21, probably being our biggest one down syndrome. They're going to have a lot of tone issues there. 22Q, the 11.2 deletion syndrome, so also known as DeGeorge. There's some people label it DeGeorge. They all come with their own set of difficulties that you really need to research what those syndromes look like in terms of feeding. Some other differentials, we definitely get more referrals, especially from swallow studies of a kid who is not making progress in therapy. There may be one of those seemingly normal aspirators. We would like to look for a laryngeal cleft. I think that that is on top of mind with a lot of people now, and we are definitely diagnosing it a lot more, especially over the past 5 to 10 years.

Neuromuscular Electrical Stimulation in Infants with Feeding Difficulties: Indications & Implementation

Neuromuscular electrical stimulation is a specialized intervention in infants with feeding difficulties, aimed at inducing muscle contractions to address identified swallowing deficits. Clinician should understand the specific pathophysiology behind each patient's swallowing difficulty before deploying NMES. Unlike the broader applications for adults, pediatric use requires thorough discernment, often supported by video swallow studies or FEES, to determine which muscle groups to target. The application, grounded in training and careful electrode placement, doesn't benefit every child, and more research is essential to evaluate its long-term outcomes.

[Dr. Gopi Shah]
Who are the kids that need the neuromuscular stimulation? Is that just your poor tone kids or is there a criteria?

[Ashley Brown]
Yes, so again it's all about function. We need to know what the deficit is before we treat it. What is the pathophysiology of their swallowing deficit? You can't just come in, do NMES without actually knowing what you're targeting and what the deficit is. It gets a bad rap, a bad name. There's not a ton of pediatric research out about it. When we're talking in terms of NMES, more and more pediatric dysphagia research is coming out, but it definitely lags behind our adult colleagues but that's how most things are in pediatrics, right?

[Dr. Gopi Shah]

[Ashley Brown]
With the NMES, it can be that, for lack of a better term, seemingly normal aspirators where we can't quite figure out there's no other comorbidities that we have yet to figure out. We use it, yes, low tone, high tone, some of our CP kids, our situation management kids because NMES essentially the easy way to describe it is you're inducing a muscle contraction. It's like the TENS units you would use on your back or legs. You're inducing a muscle contraction, but it also impacts that surface sensory as well, because they are short electrical pulses.

That's the theory behind it. Does it work for every kid? No, it does not. Do we see some good outcomes? Yes, we do. We need definitely more research on the long-term outcomes. Is this sustainable as soon as the therapy is done? Do they regress? That I think, is where we need more information but you should be very thoughtful in how you use it and recommend it because you need to know the pathophysiology behind their swallow deficit before implementing NMES, because you need to know what to target and not go in blind.

[Dr. Gopi Shah]
Meaning where exactly you're going to, which muscles to stimulate and where you're going to place your electrodes based on what you see in the video swallow or what you physically see?

[Ashley Brown]
Correct. Yes, so with the video swallow or the FEES, there are different electrode configurations that in theory target different muscle groups. You go through training. Everyone who uses it goes through training and you get information and handbooks on these electrode placements target this group of muscles, and this deficit pathophysiology you saw on the swallow study. You have to be very precise about it. It's not for every kid. A lot of our kids we'll try it. We'll get NMES for a little while and we see no progress or benefits that may happen but it's up to that treating therapist to really think through the deficit and what they're targeting.

Podcast Contributors

Ashley Brown, SLP discusses Feeding Difficulties in Infants on the BackTable 48 Podcast

Ashley Brown, SLP

Ashley Brown, SLP is a pediatric speech language pathologist at Children's Health in Dallas.

Dr. Gopi Shah discusses Feeding Difficulties in Infants on the BackTable 48 Podcast

Dr. Gopi Shah

Dr. Gopi Shah is a pediatric otolaryngologist and the co-host of BackTable ENT.

Cite This Podcast

BackTable, LLC (Producer). (2022, February 8). Ep. 48 – Feeding Difficulties in Infants [Audio podcast]. Retrieved from

Disclaimer: The Materials available on are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.



Feeding Difficulties in Infants with Ashley Brown, SLP on the BackTable ENT Podcast)


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Pediatric FEES: Protocols, Feeders & Ergonomics in Cardiac Care

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Evaluating Infant Feeding Difficulties: The Role of FEES & VFSS

Evaluating Infant Feeding Difficulties: The Role of FEES & VFSS


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