Background: Feeding difficulties, including aspiration risk, are common in children with Down syndrome. Identifying factors affecting feeding modality is crucial. Method: This cross-sectional study included 335 children with Down syndrome (aged 4-12 years; mean 5.2). Feeding was assessed using the Functional Oral Intake Scale (FOIS), the Screening Tool of Feeding Problems (STEP), and clinical observation. Aspiration risk was identified through STEP items and clinician evaluation. FOIS scores categorised feeding as oral or non-oral. Results: Of participants, 74.1% were oral feeders and 25.9% received non-oral nutrition. Aspiration risk was present in 33.7%. Cluster analysis revealed distinct subgroups defined by aspiration, oral sensory issues, and behavioural problems. Younger age was significantly associated with higher aspiration risk (OR = 0.38, p = 0.001). Conclusions: Aspiration risk influences feeding modality and subgroup characteristics. Early multidisciplinary assessment is essential, especially for younger children, to detect risk and guide safe, individualised feeding strategies.