Can I begin oral intake in a fully awake, alert 2‑year‑old with an open, non‑depressed frontal bone fracture and a small frontal contusion hematoma?

Can You Begin Oral Feeding in This 2-Year-Old?

Yes, you can begin oral feeding in a fully awake and alert 2-year-old with a non-depressed frontal bone fracture and small frontal contusion hematoma, provided the child passes a dysphagia screening first. 1

Mandatory Pre-Feeding Assessment

Before allowing any oral intake, you must complete a dysphagia screening because:

• All stroke and brain-injured patients who are awake and alert should be screened for dysphagia before oral intake is allowed 1
• The child must be alert, awake, and able to accept food and liquids into the mouth to swallow safely 1
• Extremely lethargic patients or those with inconsistent levels of alertness are at increased aspiration risk and should not be fed orally 1

Dysphagia Screening Protocol

Perform a simple bedside water swallow test:

• Observe the child drinking small amounts of water (3 oz) 1
• Watch for clinical signs of aspiration: coughing, wet/gurgly voice, throat clearing, or hoarse voice after swallowing 1
• If the child coughs or shows any of these signs, refer for detailed swallowing evaluation before allowing oral intake 1
• If the child passes the screening without coughing or voice changes, oral feeding may proceed 1

Why This Patient Can Likely Feed Safely

The clinical scenario suggests low aspiration risk because:

• The fracture is non-depressed (no significant brain compression) 2, 3
• The contusion hematoma is small (minimal mass effect) 3
• The child is fully awake and alert (preserved level of consciousness) 1
• Open frontal bone fractures without posterior table involvement or CSF leak typically do not require immediate surgical intervention 2, 3

Contraindications That Would Prevent Feeding

Do NOT allow oral intake if the child exhibits:

• Lethargy or reduced level of consciousness 1
• Absent swallow response on command 1
• Inability to manage oral pharyngeal secretions (requiring frequent suctioning) 1
• Abnormal upper airway sounds 1
• Respiratory rate >35 breaths/min 1

Practical Feeding Strategy Once Cleared

After passing dysphagia screening:

• Allow the child to self-feed 1
• Use low-risk feeding strategies: appropriate diet consistency, reduce distractions during meals, seated position, slow feeding rate with small amounts per bite 1
• Start with clear liquids, then advance to age-appropriate diet as tolerated 4
• The European Society for Clinical Nutrition and Metabolism recommends oral intake can be initiated within hours of surgery in most patients; fluids can start almost immediately, but solids should be introduced more cautiously 4

Common Pitfalls to Avoid

• Never assume a "fully awake" child can swallow safely without screening—even minor brain injuries can impair swallow coordination 1
• Do not delay feeding unnecessarily if the child passes screening; prolonged NPO status in a stable patient increases risk of malnutrition 1
• Watch for delayed deterioration—if the child becomes lethargic or develops new neurological signs after feeding begins, stop oral intake immediately and reassess 1, 5