Abstract
This AOTA Position Statement defines the role of occupational therapy practitioners and describes their distinct approaches and value in the delivery of occupational therapy services for people with feeding, eating, and swallowing impairments and performance limitations.
This AOTA Position Statement defines the role of occupational therapy practitioners and describes their distinct approaches and value in the delivery of occupational therapy services for people with feeding, eating, and swallowing impairments and performance limitations.
Opening Statement
Feeding, eating, and swallowing are complex, life- sustaining, and valued occupations and co-occupations across the lifespan. These occupations are activities of daily living (ADLs; American Occupational Therapy Association [AOTA], 2020a) that contribute to overall well-being and have both symbolic and practical meaning for individuals and families (Haertl, 2018). Feeding and eating, which are essential to human survival and functioning, are influenced by a person’s culture, including food choices, rituals around eating, and the social meaning of eating.
Occupational therapy practitioners (i.e., occupational therapists and occupational therapy assistants) have long-standing expertise in evaluating and supporting ADL performance, including involvement in the feeding, eating, and swallowing performance of infants, children, youth, adults, and older adults (AOTA, 2020a). Occupational therapy practitioners provide essential services in the comprehensive management of feeding, eating, and swallowing problems. The purpose of this Position Statement is to define the role and describe the distinct approaches and value of occupational therapy practitioners in the delivery of occupational therapy services for people with feeding, eating, and swallowing impairments and performance limitations. Occupational therapy practitioners are uniquely positioned to evaluate, design, and implement interventions for difficulties associated with feeding, eating, and swallowing because of the profession’s holistic perspective of recognizing and evaluating not only the physiological, motor, and sensory factors but also the psychosocial, cultural, and environmental factors involved with these aspects of daily performance (AOTA, 2020a). Problems addressed may include difficulty with preparation of meals, physically bringing food to the mouth, orally managing liquid and food, and the efficiency and effectiveness of the swallow (e.g., dysphagia). Occupational therapy can also support chest/breast feeding (MacDonald et al., 2016), structural and anatomical differences, psychologically based eating disorders, restricted eating related to sensory-processing patterns, and dysfunction related to neurological or cognitive impairments.
Definitions
For this official document’s purposes, the following broad definitions are noted: ▪ Feeding is the term used to describe the process of bringing food to the mouth and is “sometimes called self-feeding” (AOTA, 2020a, p. 30). ▪ Eating is defined as “keeping and manipulating food or liquid in the mouth and swallowing it” AOTA, 2020a, p. 30). ▪ Swallowing is “moving food from the mouth to the stomach” (AOTA, 2020a, p. 30) and can be further defined as the esophageal phase of swallowing, which consists of the passage of food through the esophagus to the stomach (Rinaldi et al., 2023). ▪ The pre-oral phase consists of overall readiness, alertness, desire, and positioning for oral intake (Rinaldi et al., 2023). ▪ Dysphagia is defined as difficulty swallowing (National Institute on Deafness and Other Communication Disorders [NIDCD], 2014), including pain with swallowing, inability to swallow, or swallowing with aspiration. □ Oral dysphagia is difficulty in the oral phase of the swallow. This involves sucking, chewing, and propelling the food from the lips to the throat (NIDCD, 2014). □ Pharyngeal dysphagia is difficulty in the phase of the swallow as the food or drink passes from the oropharynx into pharynx. During this phase of the swallow, the epiglottis folds backward to protect the airway. Dysphagia in this phase often results in aspiration of food and/or drink (NIDCD, 2014). ▪ Aspiration is when pharyngeal secretions, food material, or gastric secretions enter the larynx and trachea and can descend into the lungs, causing an acute or chronic inflammatory reaction. Individuals who aspirate are at an increased risk for medical complications that include, but are not limited to, airway obstruction and aspiration pneumonia (Ficke et al., 2023). ▪ The International Dysphagia Diet Standardisation Initiative (IDDSI) is a framework that standardizes the characteristics of food and liquid at each diet level while providing testing methods to ensure consistency across meals (IDDSI, 2019). This standardization provides more consistency among institutions, clinicians, and caregivers, thus ensuring safety for the clients whom occupational therapy practitioners serve. For more information regarding IDDSI and different food consistencies refer to: www.iddsi.org. ▪ Avoidant restrictive food intake disorder is an eating or feeding disturbance (e.g., apparent lack of interest in eating or food avoidance that is based on the sensory characteristics of food, concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and energy needs associated with one (or more) of the following: significant weight loss (or failure to gain), significant nutritional deficiency, dependence on enteral feeding or oral nutritional supplements, marked interference with psychosocial functioning that is not attributable to a medical condition or other mental health condition (American Psychiatric Association, 2013). ▪ Pediatric feeding disorder is impaired oral intake that is not age appropriate and is associated with medical, nutritional, feeding skill, and/or psychosocial dysfunction (Goday et al., 2019). ▪ Nonnutritive sucking is used when an infant is sucking without the intent of gaining any kind of nutrition. Sucking on a pacifier is nonnutritive sucking (Marcus & Brenton, 2022). ▪ Pre-feeding relates to the skills or tasks that are needed prior to initiating any feeding. For example, in an infant, maintaining strong and consistent sucking on a pacifier is considered a pre-feeding skill (Bickell et al., 2017). ▪ Breastfeeding is the mother–child act of milk transference, and exclusive breastfeeding means that no other liquid or solid food is fed to the infant, with the exception of medicines (Chantry et al., 2015). ▪ Chest feeding has become the preferred gender- neutral term to describe an infant feeding from the chest of their parent to receive human milk as nutrition (Centers for Disease Control and Prevention, 2024; Yang et al., 2023). The Academy of Breastfeeding Medicine supports that a lactating person should be encouraged to choose whichever terms for milk and feeding with which they identify (Bartick et al., 2021).
Importance and Significance
Difficulty with feeding, eating, and swallowing is a significant concern across the lifespan, in both the general population and in populations of individuals with health conditions and disabilities. In the pediatric population, up to 25% of otherwise-healthy children, and up to 80% of children with developmental disabilities, are reported to have feeding disorders (Adkins et al., 2020; Kovacic et al., 2021). Feeding, eating, and swallowing challenges persist across the lifespan. As many as 60% of individuals with underlying neurological conditions and up to 31% of healthy individuals have reported difficulty with swallowing and related problems; however, few report or discuss concerns with a clinical provider (Adkins et al., 2020; Ribeiro et al., 2024). Poor feeding and eating outcomes can include life-threatening events, such as aspiration and gastroesophageal reflux disease, malnutrition, failure to thrive, and bowel obstruction (Dudik et al., 2018; Duncan et al., 2017), as well as poor outcomes related to social and emotional functioning, attachment, and family functioning.
Occupational therapy practitioners address feeding across the lifespan and across practice settings and the continuum of care. They work with neonates in intensive care settings (NICU) to support nonnutritive skills and transitions from acute care to home. Home and community practice settings support infants and parents with breast or chest feeding and bottle feeding, moving them through the developmental skills needed to transition to solid foods and thin liquids. For people who receive nutrition through tube feeding (enteral feeding), occupational therapy practitioners work with the treatment team to help clients transition from tube feeding, if medically appropriate, or to incorporate their tube feedings into their daily lives and social interactions. With advanced training and competency, evaluation and intervention strategies can be provided to clients with dysphagia related to acute and chronic neurological conditions. Occupational therapy practitioners also work with older adult clients who lose the ability to eat solid foods and thin liquids safely because of a variety of conditions related to aging, dementia, or other medical issues. Interventions with this population include providing adaptive environments and equipment, teaching swallowing exercises and techniques, modifying food consistencies, and self-feeding strategies to help an individual continue to eat and drink safely.
The Occupational Therapy Process
Occupational therapy practitioners with entry-level practice skills have the basic knowledge and skills to provide occupational therapy services to clients who experience barriers and limitations during mealtime routines.
Evaluation
An occupational therapy evaluation begins with a comprehensive Occupational Profile (AOTA, 2021a). This includes gathering information from the client and caregiver regarding mealtime habits, routines, performance patterns, and contexts. The occupational therapy evaluation also includes information about the meaning and cultural value placed on mealtime and food-oriented rituals and food preferences. Occupational therapists are trained to conduct comprehensive evaluations, which include selecting, administering, and interpreting assessment measures to gather information about motor, sensory, cognitive, and psychological factors related to feeding, eating, and swallowing. From this, occupational therapists interpret evaluation results, develop goals in collaboration with the client, and plan specific intervention strategies to achieve therapeutic outcomes related to feeding, eating, and swallowing in the context of the client’s daily routines. Occupational therapy evaluations may include a variety of assessment tools and strategies that are based on client needs and goals and on practitioner training and competence, including skilled clinical observation, proxy report questionnaires, and clinical bedside swallow evaluations. Occupational therapy assistants may gather data and administer selected assessment tools or measures for which they have demonstrated competence (AOTA, 2020b, 2021b) and collaborate with occupational therapists to interpret findings.
Interventions
Occupation-centered interventions focus on the components that enhance the person’s ability to participate in eating and feeding routines that are valued and fulfilling to that person, such as eating independently, joining friends for lunch, and feeding a child. Mealtimes may be considered a co-occupation or family occupation or may be situated in a social context and affect the individual’s overall health and well-being. Occupational therapy practitioners include the family and other valued mealtime participants in the evaluation and intervention process (Smith et al., 2020). Interventions can include environmental modifications, promotion of effective mealtime positioning, use of adaptive equipment, feeding and swallowing modification strategies, techniques for establishing and restoring performance skills, adjustment and support of mealtime routines and food consistencies, and client and caregiver education.
Occupational therapy practitioners have a role in advancing feeding, eating, and swallowing performance skills and participation. Occupational therapists are trained to develop specific intervention plans and provide therapeutic interventions to address or adapt feeding, eating, and swallowing skills across meaningful contexts in the client’s daily life. Both occupational therapists and occupational therapy assistants select, administer, and adapt activities that support the intervention plan. The intervention activities and strategies are consistent with the occupational therapy assistant’s demonstrated competency and delegated responsibilities (AOTA, 2020b, 2021b).
Outcomes
Outcomes of occupational therapy interventions can include, but are not limited to, increased intrinsic motivation to eat (volume and variety of intake); an increase in and support of specific mealtime behaviors; safe swallowing, efficiency, and control in self-feeding; improved social participation during the mealtime experience; and reduced caregiver strain or parenting stress (Borowitz & Borowitz, 2018; Johnson et al., 2019; Kwon et al., 2020; Simione et al., 2020). In addition, improvements in feeding, eating, and swallowing contribute to greater quality of life, increased health outcomes, and improved community participation. In some contexts, formal standardized assessment tools and proxy report questionnaires are used to measure outcomes of intervention.
Interprofessional Considerations
Collaboration with the interprofessional team when delivering occupational therapy services related to feeding, eating, and swallowing is best practice. It is essential that occupational therapy practitioners articulate their distinct role and communicate closely with all members of the team (AOTA, 2024). Across settings, members of the interprofessional team can include physicians, dietitians, lactation professionals, speech-language pathologists, psychologists, psychiatrists, and social workers. It is imperative that occupational therapy practitioners develop strong clinical reasoning and communication skills to understand the role of other disciplines and how scopes of practice overlap to facilitate successful participation in occupations related to feeding, eating, and swallowing. Occupational therapy practitioners must be aware of responsibilities and allowances of and limitations to their own professional scope of practice, training and experience, and state practice act provisions and be ready to make an appropriate referral to another member of the interprofessional team if warranted.
Advanced Feeding, Eating, and Swallowing Practice
Occupational therapists with advanced-level practice skills in feeding, eating, and swallowing have expanded depth and specificity of knowledge related to evaluation and intervention. This knowledge includes more complex evaluations and interventions for clients who are medically fragile or who have complicated diagnoses or conditions resulting in feeding, eating, and swallowing problems. In populations with complicated feeding and swallowing problems, such as postsurgical cancer patients, patients in intensive care units, or premature infants, the interplay of medical and developmental factors is complex and requires specialized knowledge to provide safe and effective service.
Occupational therapists with advanced-level practice skills contribute to the development of new and innovative approaches to evaluation and intervention. They may develop skills for instrumental evaluations (e.g., videofluoroscopy, cervical auscultation, ultrasonography, fiberoptic endoscopy, scintigraphy, manometry, electromyography) relevant to their area of practice. Occupational therapy assistants with advanced-level knowledge and skills have built on their foundational education and training to provide more comprehensive interventions. Occupational therapy assistants with advanced-level practice skills have gained extensive knowledge and experience in the feeding, eating, and swallowing needs of specific client populations or clients in specific settings. The increased depth of knowledge allows occupational therapy assistants to provide services to clients who are more medically fragile or whose problems or needs are more complex than those addressed by occupational therapy assistants with entry-level practice skills. Occupational therapy assistants with advanced-level knowledge may assist occupational therapists in carrying out instrumental swallowing evaluations.
Ethical, Legal, and Regulatory Considerations
Occupational therapy practitioners have a professional and ethical responsibility to provide services only within each practitioner’s level of competence and scope of practice. The AOTA Occupational Therapy Code of Ethics (the Code; AOTA, 2025) establishes principles that guide safe and competent occupational therapy practice and that must be applied when addressing feeding, eating, and swallowing. Occupational therapy practitioners should ensure that they understand all physiological aspects and medical contraindications for a client before beginning the occupational therapy process to address feeding and eating. The Code emphasizes the Principle of Autonomy by affirming the right of clients to make informed decisions about their care. In the context of feeding interventions, occupational therapy practitioners must consider strengths-based and neurodiversity-affirming strategies that respect a client’s choices, preferences, and cultural values while providing evidence-based recommendations. Practitioners should refer to relevant principles in the Code and comply with state and federal regulatory requirements. Occupational therapists and occupational therapy assistants collaborate to meet the needs of the specific setting and population. Occupational therapists and occupational therapy assistants may also supervise other nonlicensed health care aides providing feeding and eating assistance to clients (AOTA, 2020b). Occupational therapists and occupational therapy assistants with entry-level practice skills, or who have had limited opportunities for hands-on experience with feeding, eating, and swallowing management, should seek supervision and mentoring from more experienced occupational therapy practitioners.
Education and Training
The educational standards for entry-level occupational therapy education programs include the biological and physical sciences related to the structure and function of feeding, eating, and swallowing (Standard B.1.1, Accreditation Council for Occupational Therapy Education® [ACOTE®] 2023; see also ACOTE, 2018); the behavioral and social sciences (ACOTE Standard B.1.1); and standards related to the evaluation and interventions for dysphagia and disorders of feeding and eating to enable performance and to train others in precautions and techniques while considering client and contextual factors (ACOTE Standard B.3.13). These standards provide the foundational skills for understanding impairments in feeding, eating, and swallowing. During their education and training, occupational therapists and occupational therapy assistants develop specialized skills in activity analysis and synthesis, allowing them to consider the interplay of physical, environmental, and sociocultural factors in providing effective services to people with eating, feeding, and swallowing dysfunction across the lifespan and continuum of care. Depending on the state regulations and which aspect of feeding, eating, and swallowing is being addressed by the occupational therapy practitioner, advanced training may be required by state practice acts, in any setting. The amount of supervision provided to an occupational therapist or occupational therapy assistant in feeding, eating, and swallowing should directly relate to their training, experience, and specific regulations of state practice acts.
Funding and Reimbursement
Occupational therapy practitioners use feeding, eating, and swallowing interventions with individuals across the lifespan with a variety of diagnoses across the continuum of care. Given the diverse use of evaluation and intervention strategies, funding and reimbursement are contingent on diagnosis, practice setting, third-party payer, and geographic location. Practitioners must become familiar with relevant codes in the International Statistical Classification of Diseases and Related Health Problems (10th Revision; World Health Organization, 2019) related to feeding, eating, and swallowing dysfunctions, including codes specific to pediatric feeding disorders. It is critical to understand and follow third-party payer policies in the state of service delivery. Occupational therapy practitioners may need to educate payers about the need for feeding, eating, and swallowing interventions; the expected outcomes of intervention; and the distinct value of occupational therapy in achieving those outcomes.
Conclusion
Occupational therapy practitioners work with individuals across the lifespan who have limited occupational performance related to feeding, eating, and swallowing. Occupational therapists evaluate clients with feeding, eating, and swallowing problems from a unique, holistic perspective and take into consideration physiological, psychosocial, cultural, and environmental factors that support or interfere with this crucial ADL. Occupational therapy practitioners provide individually tailored interventions to establish or restore skills to address the specific feeding, eating, or swallowing problem; adapt the environment to support safe eating habits; provide adaptive equipment; and educate families and others in the community about safe and effective feeding and eating routines and strategies.
Additional Resources
Rinaldi, E., Avery, W., Hatlevig, J., & Bernard, S. (2023). Adult feeding, eating, and swallowing: Occupational therapy dysphagia management. AOTA Press.
Marcus, S., & Breton, S. (Eds.). (2022). Infant and child feeding and swallowing: Occupational therapy assessment and intervention (2nd ed.). AOTA Press.
Authors
Shelley Coleman Casto, MS, OTR/L, BCP, CPST
Meredith Gronski, OTD, OTR/L, CLA, FAOTA, Chairperson, for the Commission on Practice
Revised by the Commission on Practice, 2024.
Adopted by the Representative Assembly, March 2025.
Note. This revision replaces the 2017 document “The Practice of Occupational Therapy in Feeding, Eating, and Swallowing,” previously published and copyrighted in 2017 by the American Occupational Therapy Association in the American Journal of Occupational Therapy, 71(Suppl. 2), 7112410015. https://doi.org/10.5014/ajot.2017.716S04
Copyright © 2025 by the American Occupational Therapy Association, Inc.
Citation. American Occupational Therapy Association. (2025). Feeding, eating, and swallowing approaches in occupational therapy. American Journal of Occupational Therapy, 79(Suppl. 3), 7913410220. https://doi.org/10.5014/ajot.2025.79S305
Footnotes
Acknowledgments
The Commission on Practice acknowledges the authors of the 2017 version of this document: Cheryl Boop, MS, OTR/L, and Jerilyn Smith, PhD, OTR/L, and authors of previous versions: Pam Roberts, MSHA, OTR/L, CPHQ, FAOTA; Marcia S. Cox, MHS, OTR/L; Susanne Holm, MS, OTR, BCN; Sharon T. Kurfuerst, MEd, OTR/L; Amy K. Lynch, MS, OTR/L; and Linda Miller Schuberth, MA, OTR/L.