This post was definitely a new direction for me: Food Chaining in dysphagia management.

My interest was sparked by a consultation with a cancer patient and deepened while developing a pediatric dysphagia course.   So, I started learning more about Food Chaining.

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What Is Food Chaining?

Food Chaining is a therapeutic approach designed to treat aversive feeding behaviors and pediatric dysphagia. It’s not only useful in pediatrics, but also shows promise for medically complex adults—especially patients who are NPO due to conditions like cancer or post-surgical complications.

When working with infants or children who are NPO (non-oral), Pre-Chaining strategies may be implemented to build foundational skills for feeding and swallowing. These techniques focus on taste, texture, and oral-sensory stimulation to reduce the risk of feeding aversion and support swallowing rehabilitation.

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Why It Matters

• 26% of preterm infants are reported to have dysphagia.
• NPO status can reduce salivary flow and the frequency of spontaneous (dry) swallows.
• In infants, nasopharyngeal reflux can lead to complications like apnea, choking, and pneumonia.
• Feeding aversion is reported in 25–35% of typically developing children—an alarming rate with serious implications for nutrition and development.

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Goals of Pre-Chaining and Food Chaining

Whether pediatric or adult, the overall treatment goals are:

• Swallow rehabilitation
• Taste and texture stimulation
• Oral-motor skill development
• Feeding skill acquisition
• Prevention or reduction of feeding aversion

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Pre-Chaining Strategies

For infants not yet ready for oral intake:

• Soothie pacifiers can promote lingual groove development and oral stimulation.
• Pacifiers dipped in breast milk or formula introduce safe taste stimulation.
• Tools like the Bionix bottle or Hazelbaker finger feeder allow small liquid trials as tolerated.
• Respiratory status, strength, and endurance must always be considered before progressing.

At 5–6 months, pre-spoon and cup training can begin:

• Textures and mouthing tools (e.g., Duospoon, Trichew) can be introduced.
• Flavor is added to promote sensory exploration and positive feeding associations.

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Food Chaining: A Stepwise Evaluation and Treatment Model

The Food Chaining evaluation includes:

1. Medical evaluation
2. Nutritional assessment
3. Oral-motor and swallowing assessment
4. Sensory and motor function assessment (fine and gross)
5. Behavioral analysis
6. Food chaining assessment and food log

This team-based process involves the SLP, OT, PT, dietitian, and physician. A detailed food log helps determine starting points based on the child’s preferred flavors and oral motor capabilities.

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Sample Food Chain: Animal Cracker to Real Meals

Here’s a simple example of how food chaining might work for a child whose core preferred food is animal crackers:

1. Animal Crackers → Teddy Grahams → Graham crackers → Shortbread cookies
2. Add: Club crackers, Ritz, saltines, peanut butter cookies
3. Add: Ritz Bits, quesadilla, grilled cheese
4. Expand: Peanut butter sandwiches → PB&J, granola, nuts
5. Explore: New pairings (peanut butter + banana, celery, apple)

Flavor masking techniques (e.g., dips, condiments, cinnamon-sugar) may ease transitions to new foods.

Children and families are also taught about the sensory properties of food and participate in theme-based meals to build familiarity and confidence.

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A Personal Clinical Case: Food Chaining in Oncology

I was consulted on a complex case: a patient post-chemotherapy and radiation, NPO by choice. She couldn’t tolerate tube feeds and relied on TPN. All food odors triggered nausea, and nothing seemed palatable.

After exhausting our options, another SLP suggested food chaining. It was worth a try.

Surprisingly, melon was the breakthrough flavor. Starting with small amounts of different melon varieties, we began rebuilding trust with food. Over time, we experimented with other fruits—some successes, some not—but she gradually expanded her intake. Though her nutritional volume remained limited, this was a significant step forward.

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Final Thoughts

This article is a must-read for anyone exploring alternative feeding strategies in dysphagia, especially in challenging cases. Food Chaining and Pre-Chaining offer practical, patient-centered approaches that respect the sensory and emotional experiences of feeding.

If you’re curious to learn more:

• Read the original article by Fraker & Walbert referenced below.
• Explore the Food Chaining book.
• Join the Food Chaining Facebook group or read their blog.

And don’t forget to consider the implications for adults—especially those who’ve experienced prolonged NPO status, chemotherapy, or surgical resections. Food chaining isn’t just for pediatrics anymore.

Are you ready for a deeper dive with even more resources available? Join the Dysphagia Skills Accelerator today. You will get so many great tools with new tools being added all the time! Click here to join now!

Have you ever wanted a way to create a more standardized protocol for your Clinical Swallow Evaluation?   Do you often forget or leave out parts of the CSE, you know, the parts that are important for your Plan of Care?  You probably need the Clinical Dysphagia Assessment Toolkit if you answered yes.   You can get your copy here.  

References:

Fishbein, M., Cox, S., Swenny, C., Mogren, C., Walbert, L., & Fraker, C. (2006). Food chaining: a systematic approach for the treatment of children with feeding aversion. Nutrition in clinical practice, 21(2), 182-184.

Fraker, C., & Walbert, L. (2011). Treatment of selective eating and dysphagia using pre-chaining and food chaining© therapy programs. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 20(3), 75-81.