Feeding in School

Schools receiving federal monies for school meals are mandated (U.S. Dept. of Agriculture- National School Lunch Program 7CFR Part 210.10 [g] [1]) to provide substitutions at no extra cost to a child whose primary medical doctor has determined that he/she has a disability that prevents him/her from eating regular school lunch. The mandate indicates that a school is not required to purchase formula for a child’s tube feedings, but it does include an expectation that the school provide appropriate foods that could be used for tube feedings. (See Appendix C: National School Lunch Program/School Breakfast Program, Meal Substitutions for Students with Disabilities, Medical, or Other Special Dietary Needs [DRAFT].)

When difficulties with eating, drinking or participation in mealtime activities arise, the health, safety, and well being of the student may be compromised. Children with critical medical conditions may need special assistance during mealtimes, especially when there is a transition from non-oral feeding to oral feeding. A plan for enhanced safety through proper positioning, appropriate texture of foods and liquids, and specific procedures for feeding and drinking should be established. (Refer to Dysphagia/Swallowing Plan form on page F-21.) The educational team needs to collaborate with the student’s primary care physician to develop this plan. Collaboration and consultation between the hospital team and school team is essential, especially for students in the transition phase and returning to school. The educational team’s goal is to focus on the student’s participation in lunch or snack routines, NOT to meet medically based outcomes.

An interdisciplinary team approach is best to address issues and concerns to meet the student’s need(s). Such an approach allows for an exchange of information and sharing of strategies among professionals. The team is made up of (but not limited to) parent(s), primary care physician, classroom teacher, educational aide, school and community speech pathologist, school and community occupational therapist, school and community physical therapist, nutritionist, school behavior health personnel, and administrator. For the community sector, the team leader is usually the physician. In the school sector, the team leader is usually the classroom teacher.

Dysphagia and Feeding Considerations

Dysphagia is defined as the inability to swallow or difficulty in swallowing. It is characterized by the difficulty in the oral preparation of food or saliva in the process of swallowing and/or in the movement of the materials from the mouth to the stomach. Included in this definition are problems in the positioning of food in the mouth and in the oral manipulation preceding the swallow (i.e., suckling, sucking, and mastication/chewing).

Dysphagia is NOT considered a specific eligibility for special education; however, some students may have other disabilities of which dysphagia is an accompanying disorder. Students who are at risk for dysphagia would be those who have the following:

• history of:
  • aspiration pneumonia,
  • lung disease,
  • neurological disease and/or insult,
  • head/neck tumor, surgery, or treatment,
• history of laryngeal closure problems,
• cervical spine injury,
• severely reduced mental status,
• presence of aspiration pneumonia – fever, infiltrate, secretions, etc.,
• presence of nasogastric tube or gastric tube, and/or
• presence of tracheotomy and/or ventilator.

Symptoms of Dysphagia:

• inability to recognize food,
• difficulty placing food in the mouth,
• inability to control food or saliva in the mouth,
• coughing before, during and/or after a swallow or immediately after a meal,
• gagging,
• facial grimacing,
• reddening of the face,
• audible breathing,
• recurring pneumonia,
• weight loss when no other reason can be defined,
• gurgly voice quality, and/or
• chronic low grade fever.

Primary concerns within the school system for students with dysphagia:

• adequate nutrition and hydration,
• safety of student during oral feeding,
• information on the exact nature of the student’s oropharyngeal swallowing disorder, and/or
• proper clearances on file for sharing information and referring students for needed medical follow-up related to dysphagia.

Developing a Dysphagia/Swallowing Plan

1. Contact the school speech-language pathologist, nurse, occupational therapist, and physical therapist to develop a feeding plan for the student. The plan should involve:
• positioning to adjust seating or posture for eating;
• equipment needed such as specific utensils that can be easily managed;
• diet and food preparation;
• the feeding plan techniques to address chewing and swallowing; and
• modification of the environment so that it is free of distractions.
2. Should problems or concerns persist, it is recommended that the parents/family follow up with their primary care physician to obtain a swallowing assessment. Parents should be given a copy of the feeding plan in order that the hospital’s dysphagia team can review the information.
3. Written consent should be obtained from the parent to allow open communication and discussion between the hospital’s dysphagia team and the school team.
4. If the parent(s) refuses consent or to have the swallowing evaluation conducted, a team member who has good rapport with the parent(s) should explain the importance and value of the swallowing assessment. It should be conveyed that the school is looking after the safety and well-being of the student. After all attempts have failed to convince the family to obtain a swallowing evaluation, a feeding team member should request permission to contact the primary care physician. If permission to contact the physician is denied, the public health nurse servicing that school should be contacted to participate and assist in the process.
5. Develop the dysphagia/swallowing plan with input from the treating hospital/facility team, and ensure that all team members (especially the classroom staff) are familiar with and understand the plan.

Tube Feedings

In some children, dysphagia is so severe that the child should not or cannot swallow anything and may require permanent surgical closure of the esophagus to prevent aspiration. A tube may be surgically inserted directly into the stomach (gastrostomy), through the nose (nasogastric), or through the mouth (orogastric) to provide hydration, feeding, or administration of medication. A qualified individual can give liquid or semi-liquid foods directly through the tube. The physician prescribes the amount of food. The child’s feeding, at any mealtime, should be a social event where the child can join others during their regular meals. If oral feedings are contraindicated, this must be documented in the child’s confidential folder. Care of the mouth needs to continue even if the child is not eating. Teeth, gums, and tongue should be brushed daily.

Some children may use a combination of oral and tube/gastrostomy feedings. Feeding by mouth will be done ONLY if ordered by the prescribing physician.

Due to past trauma or discomfort experienced with dysphagia, the child may develop sensitivities or aversion to touch around the oral motor area or to food stuffs reintroduced orally. Certain health professionals, i.e., occupational therapists, nutritionists, nurses, and speech pathologists, are trained to work with feeding problems and can be consulted. Management of issues is a team effort. Continuous collaboration and consultation with community counterparts and the primary physician is essential.