Dysphagia, Speech and Language Therapy (SLT)

Paediatric dysphagia assessment, feeding and swallowing support, red flag symptoms, positioning strategies for infants, videofluoroscopy referrals, and episodic care management

Contact Details

Speech and Language Therapist, Paediatric Dysphagia Service:

Address: Barnet Children's Integrated Therapies, 3rd Floor, Westgate House, Edgware Community Hospital, Burnt Oak Broadway, HA8 0AD.
Website.
Tel: 020 3316 8900.
Email: whh-tr.barnetCIT@nhs.net.

Education Papers and Videos for Parents and Professionals (Pediatric Feeding & Swallowing Associates)

How-to feeding videos for parents with children who present with feeding & swallowing issues. How-To Videos | Pediatric Feeding.
Educational papers.

Paediatric Complex Needs and Dysphagia Speech and Language Therapy (SLT) Red Flags for Feeding, Recommended Positioning

Background

Feeding difficulties are common in babies with DS; therefore, parents must be provided with advice and support regardless of the method of feeding. Infants with DS are at increased risk of having hypotonia, which can impact feeding quality and safety. Other factors which can impact feeding include heart, reflux and respiratory problems, all of which can impact on swallow safety and therefore could delay the progression to full oral feeding. A speech and language therapist must consider the following factors during assessment:

Gestational birth age, i.e. if the baby has been born premature, then they will have an increased risk of a delay in developing competent oral feeding skills.
Assessment of early oral reflexes, i.e. rooting reflex, gag, bite reflex, and suck-swallow reflex, with a clear evaluation of oral secretion management. For sucking, assessment of the sequential nature of the patterns observed, and the type of suck pattern, e.g. disorganised, dysfunctional, etc., needs to be evaluated.
Muscle tone.
Feeding partners' responsiveness to infants' communication.
Physiological stability during NGT feeds, and /or oral feeds.

More information: Respiratory health outcomes of children with Down Syndrome following dysphagia management: a service evaluation, Himali de Silva et al. BMJ Paediatr Open. 2024. Read the paper.

Within the Down Syndrome population, there is an increased likelihood of childhood difficulties with eating, drinking and swallowing; in particular, oral-motor difficulties and sensory challenges are common. Co-morbid health conditions can further increase the likelihood of feeding difficulties.

Factors to consider

Structural differences

Low tone and open posture of the lips can cause the anterior loss of fluids/food and make it more difficult to effectively chew, and/or may mean early fatigue when chewing.
A relatively larger tongue and/or less mobile tongue can cause difficulties in manipulating and moving food within the mouth.
Solids can become stuck in a high palate.
Poor sensory awareness can mean that the child is not fully aware of where food is within the mouth or when they have chewed sufficiently to swallow, or they may have a hypersensitive gag reflex.
Infant reflexes last longer than typical, e.g., thrusting the tongue forward and pushing food out of the mouth or clamping down when presented with a spoon.
Jaw and tongue are unstable or uncoordinated, causing food to fall to the back of the mouth, prompting gagging or choking.

New Referrals

As the evidence base suggests that children with Down Syndrome are more likely to have feeding difficulties, there is a lower referral criteria threshold for this population. The following list suggests symptoms that would be of particular concern and would be best explored following a referral.

The red flags

Coughing or choking with food or fluids.
Back arching, turning away and refusing the bottle/breast or when presented with a spoon.
Airway/breathing sounds are congested or more congested when eating and drinking.
Wet/gurgly voice when eating or drinking.
Wet sounding cough when eating or drinking.
Changes in facial colour, alertness, breathing when eating and drinking.
Frequent chest infections, particularly if not during the season for respiratory illnesses.
Development of respiratory symptoms such as wheezing.
Prolonged feeding times.
Difficulties with texture progression (eg, only accepting thin puree).
Frequent vomiting when eating and drinking (possibility of reflux should be discussed with the child's doctor).

Children Previously Known to the Service

The SLT service is currently operating using an episodic care model; when a child is agreed to have a safe management plan in place, they will be discharged. Written eating and drinking guidelines will be provided, describing the management plan. It is expected that some of these children will need to be referred back to the SLT service for another episode of care if changes to the management plan need to be made (eg, due to skill development).

All discharge summaries or reports contain the following advice wording to parents/carers and professionals. An immediate referral should be made if concerns of this nature arise. We are happy to discuss individual cases and, if a referral is warranted.

If any of the signs listed below are observed, please request re-referral to the PDS team and seek medical advice.

The red flags

Coughing or choking with food or fluids.
Airway/breathing sounds are congested or more congested when eating and drinking.
Wet/gurgly voice when eating or drinking.
Changes in facial colour, alertness, breathing when eating and drinking.
Frequent chest infections, particularly if not during the season for respiratory illnesses.
Development of respiratory symptoms such as wheezing.

When children previously known to the service who have dietary modifications in place start at a new educational or care setting, written eating and drinking guidelines will be transferred to the new setting, describing the management plan. The management plan may include advice on positioning, modified diet and support strategies.

Children with longer-term dietary modifications in place, especially those on thickened fluids, should be referred for a reassessment before these modifications are ceased.

Other specific information

Videofluoroscopy - Barnet children can access videofluoroscopy if appropriate, through a referral from the SLT/dysphagia therapist to the VFSS clinic locally at the Royal Free Hospital or another hospital if the child is under a specific consultant. There can be a waiting time of several months.

It is important to seek a referral to the SLT dysphagia team if you are concerned about your baby's feeding and to assess each baby individually.

Our lead for infant assessments is: Speech and Language Therapist, Paediatric Dysphagia Service, Children's Outpatients, Edgware Community Hospital, Burnt Oak, HA8 0AD. Tel. 0208 732 6913.