Feeding development and difficulties


  • Gagging or choking - Challenges increasing textures in the diet

    • Development of oral motor skills enables children to manage foods with an increasing range of textures.
    • Gagging is a reflex action that helps to prevent choking.  It can be triggered by fingers, food, a spoon or toys touching the back of the mouth.  The gag reflex diminishes at around 6 months of age coinciding with the age at which most babies are learning to eat solid foods.  Some children have a hypersensitive gag reflex and will gag more easily.
    • Gagging is a common response when infants are making the transition from smooth to lumpy foods or when learning to chew.  It is best managed by providing graded food textures that support or match the development of oral motor skills.  Exploring of the mouth with hands and toys and encouraging feeding independence helps with diminishing the gag reflex.
    • With positive reinforcement gagging can become a learnt behaviour.  To prevent this avoid overreacting to the child’s gagging response. Simply remove the piece of food and provide reassurance.
    • Gagging is not the same as choking where the airway becomes blocked preventing breathing.  Unlike gagging where the child will make retching noises choking is silent.   Babies and young children should always be supervised when eating.

    Case scenario

    Ava aged 14 months is referred for assistance with feeding.  Her parents are concerned that Ava has a swallowing problem as she will only eat smooth puree foods.  If she is given any lumps in her food she will gag and usually vomit. 

    Remember to consider your own response before viewing suggested answers.

    Question 1

    What are the key elements of your assessment of Ava’s feeding difficulty?

    Answer Question 1

    Key elements of your assessment include:

    • Parent’s perception of the problem.
    • Medical, developmental, growth and social history.
    • Dietary assessment.
    • Observation of feeding.

    Your assessment reveals the following details:

    Parent’s perception of the problem

    • Ava’s parents report, “Ava started solids when she was almost 6 months old.   She seemed ready.  She was very interested in watching her sisters eat.  However she didn’t really seem to enjoy the foods I gave her.  She would spit a lot out.  She liked the commercial baby foods better than the foods we made for her.  They seem smoother and she managed them better.”
    • “When I tried her on the next stage foods with the lumps but she gagged and looked like she was about to choke.”   
    • “We waited a while before trying again but she still gags on the tiniest lumps.  It is getting worse and now she vomits if she finds a lump. We are sure she has a swallowing problem.”

    Medical, Developmental, Growth and Social History

    • Ava was born at term.  There are no concerns regarding her development and her growth has tracked consistently around the 25th percentile.  She has not had any significant illnesses.
    • Ava lives with both her parents.  Mum does not work and is the primary carer for Ava and her two older sisters.  Dad is employed full time.

    Dietary assessment

    • Ava has smooth infant cereal for breakfast.  Lunch and dinner typically consists of smooth commercially prepared foods that include meat and vegetables.  This is usually followed by puree fruit with yoghurt or custard.  She is either fed by mum using a spoon or self feeds by sucking food directly from the ‘pouch’.   
    • Sometimes Ava will mouth toast or biscuits until they go soggy but she doesn’t appear to swallow any.
    • Ava was breast-fed until around 10 months of age. She then commenced infant formula and is currently having 3 small bottles per day. She also has water from a cup.

    Mealtime Observation

    • Ava is well supported in a high chair.
    • She is offered lunch as described above.  She is observed to be happy and interactive when being spoon fed and enjoys the independence of feeding herself from the pouch.
    • Mum agrees to offer Ava some fork mashed fruit so that the observer can make an assessment of Ava’s response.
    • As mum predicts Ava gags and vomits.  The observer notes that mum fusses over Ava when she gags.  She has a bowl ready at the table to ‘catch the vomit’ and prevent a mess.
    • It appears that mum has a low tolerance for mess as Ava is also not encouraged to use a spoon to self-feed.

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