Oral Motor, Sensory Feeding and Picky Eaters
Feeding and swallowing problems are reported in 10-25% of all children, 40-70% in premature infants, and 70-90% in children with medical/developmental delays. The etiologies of feeding disorders are as varied as the multiple disciplines, approaches, and interventions available. All children are born hard-wired to eat. However, some children with poor oral motor skills may present with many challenges while feeding. Some children may appear to be “messy eaters”, but in reality, they may not have the strength to successfully close their lips around a spoon. Other kids may tend to rush through meals, however their oral awareness may actually be reduced and they may not even be aware of how much food is actually in their mouths. Therefore mealtimes may prove to be difficult and frustrating for children, and equally as stressful for mom and dad.
Children with developmental delays often have feeding difficulties resulting from oral-motor problems. Based on both clinical experience and a review of published studies, oral-motor interventions have been shown to be effective in improving the oral function of preterm infants and children with neuromotor disorders, such as cerebral palsy. However, oral-motor problems may be under identified in other populations of children with developmental difficulties
Oral Motor Delay
Typically present in the child with feeding problems. The suck-swallow-breathe pattern in infants may be poorly developed. Muscles of the tongue, jaw and lips may be weak with chewing patterns underdeveloped.
Weakness of the muscles of the lip, tongue, or jaw can have a great impact on the ability to manipulate food in the mouth, including chewing and swallowing. The ability to remove food from silverware and keep food from falling out of the mouth are also difficulties results from weak musculature. Having weak muscles can affect a child’s gag reflex, which makes feeding even more unpleasant. Weak musculature can also result in episodes of choking that can affect a child’s willingness to eat altogether, creating a feeding disorder. Muscles that are weak or receiving incorrect information from the brain can cause chewing, swallowing, and manipulating the food within the mouth to be hard work. When children are faced with unsuccessful eating because they gag, choke, or spend long periods of time eating, it reduces the motivation to continue with this activity. Strengthening the muscles and resetting the neural pathways is essential for improving feeding disorders.
The normal swallow requires coordination of various cranial nerves and about 26 head and neck muscles. Research has shown that as infants and toddlers transition from the bottle/breast to spoon feeding and cup drinking, their muscles are doing invaluable work.
The infant’s anatomy, during this critical phase of development, is changing along with his/her ability to use all of these muscles appropriately for feeding and later for speech. If a child has difficulty during this developmental phase, they may create strategies to compensate for a lack in coordination of muscle movement.
Feeding Aversions and Feeding Delay
Difficulty drinking from a bottle, cup or chewing solid foods and textures. Some children choke or gag on food while others drool and spill food from their mouths. Other children experience sensory issues transitioning to solids or when offered new foods. These children may be overly sensitive to specific tastes or textures or demonstrate an under-reaction to foods, craving spicy or crunchy foods.
Oral Motor/Feeding Milestones
- 4-6 months- Babies introduced to soft solid foods such as cereals and pureed fruits and vegetables. Cup drinking may also be introduced (6 months)
- 6-9 months- Soft cookies may be introduced as well as ground or lumpy solids.
- 10-12 months-Mashed or soft table foods are introduced, babies will also take most of their liquids from a cup. At 12 months, babies have a controlled bite and are able to bite through cookies.
- 13-15 months- Continued improvement with biting skills, will also use a straw or regular cup.
- 16-18 months- Children are given more challenging foods that require chewing, such as meats and vegetables.
- 19-24 months- Children will begin to gain more control of cup drinking and will bite the cup less. They are learning to drink in longer sequences with little or no spillage.
- 2 years- Children are able to manage any type of food they like as they have learned all the skills they need to eat every type of food
Oral Motor And Feeding Red Flags
- Lack of oral-exploration with non-food items as an infant
- Difficulties transitioning between different textures of foods
- Weaknesses sucking, chewing, and swallowing
- Frequent coughing and/or gagging when eating
- Reduced or limited intake
- Food refusal
- Food selectivity by type and/or texture
- Dysphagia (swallowing difficulty)
- Oral motor deficits
- Problems with the ability to take food into the mouth.
- Interfering with the buildup of negative oral pressure during sucking.
- Leaking food from the nose during sucking and swallowing.
- Inefficient handling of food in the mouth.
- Poor coordination and timing of the suck-swallow-breathe sequence.
- Exhaustion during and after mealtime.
- Gastrointestinal discomfort during mealtime (example: vomiting).
- Sensory modulation and sensory defensiveness throughout feeding.
- Delayed feeding development
- Food or swallowing phobias
- Mealtime tantrums
- Vomiting during or after meals
- Refusal to eat certain textures of foods
- Rigidity with diet
- Avoidance of touch on face and around mouth
- Loss of food and liquids when eating
- Obvious preference for certain textures or flavors of foods
- Increased congestion during and after meals
- Grimacing/odd facial expressions when eating
- Consistent wiping of hands and face during meals
- gurgly, hoarse, or breathy voice quality
- frequent spitting up or vomiting
- Pocketing of food in cheeks, or residue observed after swallow
- Irritability and anxiety during mealtime
- Excessive drooling and lack of saliva management
- Sudden refusal to eat previously tolerated foods
- Excessive weight gain or loss
Causes of oral motor disorders:
Children may experience feeding and swallowing issues as part of the following difficulties:
- Physiological (e.g., reflux, constipation, food allergies/intolerance)
- Sensory (over/under/mixed sensitivity in their mouths e.g., may not like toothbrushing or soft foods)
- Oral motor (unable to suck, or chew and swallow food)
- Behavioral (e.g., learnt behavior in response to food)
- Incorrect motor programming of the muscles of the mouth. In other words, the brain sends a message to the muscles of the mouth, but the muscles don’t receive the message or it is misinterpreted. This causes the muscles either to not move at all, or to move in an incorrect fashion that results in mismanagement of food in the mouth.
- Low muscle tone, meaning the muscles of the lip, tongue, or jaw are weak. Many times children with low muscle tone in the jaw have an open mouth posture. Difficulty with puckering, drinking from a straw, or frequent spilling of liquids when drinking is caused by weak lip strength. Poor tongue strength can result in an inability to stick the tongue out, or move it from side to side. Drooling can also be caused by weakness in the muscles of the mouth. Strengthening these muscles can be very important in improving both feeding deficits and speech intelligibility.
Addressing feeding problems may be important for preventing or eliminating nutritional concerns, growth concerns including failure to thrive, unsafe swallowing which may lead to aspiration pneumonia and future poor eating habits/attitudes.
Feeding therapy may be conducted in an outpatient clinic or hospital. Staff involved in conducting the initial feeding evaluation and any subsequent therapy will depend on the location of the evaluation and the infant or child’s current concerns. The feeding team may include one or more of the following: a speech/language pathologist, occupational therapist, physical therapist, nutritionist, social worker or other medical professionals.
Initially the evaluator will gather information about the infant or child’s medical, feeding and developmental history. Measurements of weight, height, weight to height ratio, frame size and fat stores may be taken. An observation of a typical feeding then takes place. The evaluator may then change some aspects of the feeding and note the outcomes in order to develop a plan to address the current concerns.
The evaluation itself is looking at a number of feeding skills and behaviors
Most importantly the evaluator is assessing oral-motor and swallowing skills to determine if the infant or child has a physical problem or lack of oral-motor skill that is interfering with the child’s ability to eat an appropriate diet safely. Many infants and children with GERD have delayed feeding skills because the pain they associate with feeding caused them to refuse feeding altogether or refuse certain types or textures of foods and they don’t gain the needed oral-motor experience to develop the physical skills needed to safely consume the type of diet they should be consuming. These associations can also lead them to attempt to get the feeding process over quickly as possible so they do not take to the time to use the physical skills needed to eat safely. Some children with GERD may also require tube feedings again reducing their exposure to oral-motor experiences and effecting their feeding skill development.
Observation alone may not give the evaluator all the information they need in assessing the infant or child’s physical skills for feeding. They may need to schedule a swallow study to gain more information. The swallow study will allow the evaluators to look for structural abnormalities in the swallowing mechanism and assess risk factors for aspiration (penetration in to the lungs) of foods and liquids.
A swallow study also called a modified barium swallow (MBS) or videofluoroscopic swallow study (VFSS) is very similar to an upper GI series. A radiologist and a speech language pathologist most likely will be present and will videotape the study for further review following the actual study. Barium will be mixed into various foods and drinks. The evaluator may observe the infant or child swallowing various textures of foods and thin liquids and possibly thicker liquids if needed. Most evaluators try to have the feeding be as close as a typical feeding situation so that they can study his typical swallowing pattern, so they may ask you to bring your infant or child’s own bottle, spoon, cup etc. and possibly some of the foods and drinks your infant or child typically has at home. Of course it is nothing like a typical feeding as the child will be in the radiology suite and will have to be positioned upright – possibly in a special seating system that gives them the observers the best view of the swallowing process.
The evaluators will watch the infant or child orally prepare the bolus (the portion of food or drink taken into the mouth) for swallowing – at this stage they are looking to see how well he chews his foods or pools liquid and transfers it to the back of the mouth for swallowing. Then they will look at the pharyngeal phase of swallowing – at this phase they are looking to see how efficiently the bolus passes through the pharynx. They want to make sure the swallow is strong enough to pass the bolus onto the esophagus and to make sure there is no pooling in the several sinus cavities in the pharynx. If this happens the pooled material can later spill out and penetrate the trachea and into the lungs. Some studies follow the bolus through the esophagus and into the stomach but not all do. They will also look at his ability to clear his airway if it is penetrated- if a cough is triggered and clears the airway. They will look to see if his swallow pattern changes over time.
In addition to physical skills the evaluator will also look at sensory issues that may be interfering with intake as some children have difficulty taking in information from what they see, hear, smell, touch and taste. Many infants and children with GERD often develop sensory issues in that they are or have become hypersensitive. This hypersensitivity may affect the infant or child’s acceptance of the nipple, spoon or certain tastes or textures. Think about it. If your stomach and esophagus hurt constantly, people were giving you medicine all the time (some of which may not taste great), you did not sleep well and eating made you feel worse or you had a n-g tube, you would be a little irritated by sensations like tooth brushing and lumpy food too. Some children may also be hyposensitive as well. This may effect their ability to know when they mouth is too full or make foods taste too bland which can effect their physical skills for eating as well as their desire to eat.
Assessing the feeding environment is also important. The evaluator will look at who is feeding the child, their level of stress in feeding the child, and if techniques they are using are appropriate. They ask about at the location in which the feeding typically takes place. They note if the environment distracting and whether the child is positioned appropriately. They look at the size and type of feeding utensils used and whether they are appropriate. Lastly they ask about the infant or child’s feeding schedule and sequence of the feeding, noting if feedings are too long, too often and what and when certain types of foods and drinks are offered.
The infant or child’s diet is an important factor to evaluate in terms of what food and liquid types are being offered and accepted, amounts consumed and whether there are any nutritional deficits or growth concerns.
Observing mealtime behaviors
Finally the evaluator also notes any mealtime behaviors that may be interfering with adequate intake. In noting behaviors the evaluator will look at how the feeder and the infant or child communicate with each other during the feeding, manipulative or maladaptive behaviors on part of the feeder or child and the child’s self-feeding development. Many problems can occur in this area. The child may be clearly communicating that he finished eating by turning his head yet the feeder pushes the child to eat more. The feeder may offer an endless array of choices at meals allowing the child to manipulate what he will and will not eat. The child may not be allowed to self –feed because of the feeder’s desire to control the amount of intake or cleanliness of the feeding.
The role of reflux in developing unusual eating patterns
It is clear that many infants and children with GERD develop negative associations with feeding due to the reflux pain that feeding has caused them. If their pain is not managed adequately, the infant or child may develop secondary behavioral symptoms of food refusal, selectivity and oral sensitivity which can negatively impact growth and maturation and can lead to delayed acquisition of feeding skills. Infants and children with GERD may be hypersensitive to tactile sensations therefore do not explore objects with their mouths, which can lead to a lag in the development of the oral sensori-motor skills required for feeding. Introduction of spoon feeding may be delayed due to lack of readiness skills or noted increase of symptoms with introduction of solid foods. Young children also may have difficulty advancing to textured foods and may gag or choke while feeding. These symptoms (i.e., food refusal, selectivity and oral sensitivity) put stress on the feeding relationship between the young child and caregivers and may lead to counter-productive feeding practices.
The associations that infants and children make between the pain of GERD and feeding can remain even long after the pain of GERD has subsided. Young children may also be taken off medication when the obvious symptoms of reflux disappear yet their reflux may continue silently (meaning that stomach contents go into the esophagus but does not result in vomiting) and cause continued feeding problems. Therefore it is vital that the young child receive proper medical diagnosis and treatment of reflux, especially pain relief, before attempting a feeding intervention program. Although feeding therapy can be effective in addressing many types of feeding difficulties, without effective pain management, oral-motor, sensory and behavioral feeding interventions may yield disappointing, ineffective results.
Management Oral Motor Problems
The speech pathologist has an understanding of biomechanical interrelationship of the head, neck and trunk and recognizes the impact of abnormal muscle tone, compensatory body posturing and patterns of movement that influence oral motor functioning and respiration. Specific goals in oral motor therapy include the handling of food in the mouth in coordination with swallowing and breathing to eliminate choking, gagging and aspiration.
Fortunately, there are also many activities you can easily incorporate at home to facilitate improvements with oral-motor skills.
- Blowing activities (blow-pens, instruments, whistles, etc.) help to improve posture, breath control, lip rounding, and motor-planning skills.
- Infant massage may also help to increase oral-awareness and facial tone.
- Straws, sour candies, and bubbles may help with drooling.
- Constantly exposing your child to a variety of new foods will help to avoid food jags, and increase their tolerance to different textures and tastes.
- Undertaking an oral motor program designed to strengthen the lips, jaw, and tongue. The program should utilize a developmental approach that increases in difficulty as the muscles begin to strengthen. Parents should be involved in the oral motor program, and should have an understanding of what the exercises entail. Daily practice is essential in not only improving strength in the lips, tongue, and jaw but in strengthening the neural pathways and improving motor programming.
- Utilizing food as an effective tool in strengthening the muscles of the mouth. Try blowing a marshmallow across the table to improve lip rounding. Suckers can be used to strengthen lip and tongue muscles. Have a seed spitting contest to improve tongue strength. Strengthen jaw muscles by having the child try to make deep teeth impressions in a slow poke sucker or piece of taffy.
Sensory Feeding Problems where something about the way food looks, tastes, smells, or feels is overwhelming or uncomfortable to a child. Children with sensory problems commonly have difficulty transitioning from one food texture to another. They may remain “stuck” on liquids or “stuck” on pureed or baby foods and refuse foods with more texture. Sometimes children with sensory problems have uncontrollable gagging or vomiting reactions to foods. These include all other problem behaviors that occur around meals. Examples include but are not limited to: refusal to sit at the table for meals, refusal to self feed (when able to do so), and disruptive mealtime behaviors such as throwing food, stealing food from others, crying screaming, vomiting to get out of the meal, and others.
As children approach the age of 24 months, they discover the amazing size of their mouth cavity. An endless amount of food fits in the space, and their new ability to keep the lips tightly closed against pressure from the inside seems like a miracle. This leads parents to remind them to finish what is in the mouth before taking another bite. Once the sense of sensorimotor discovery and adventure has worn off, children return to more reasonable sized mouthfuls.
Mouth stuffing can also be an important sign of sensory or motor difficulties in oral-motor control. When the mouth is fully stuffed with food, children obtain more sensory information about the boundaries of their mouths and the presence of food in the mouth. This often happens when oral sensation is reduced. The child may have a low level of awareness of the inside dimensions of the mouth and the feeling of food. The stuffing wakes up the mouth and helps the child know that there is still food in the mouth. Some children deal with a condition called oral defensiveness. These youngsters experience highly distressful sensations from food taste or texture. Unpredictable movement of the food can be very uncomfortable. Many children with oral tactile defensiveness also stuff the mouth because it reduces the random tactile input to the cheeks when smaller pieces of food are moved around.
Mouth stuffing is also present when a child has difficulty using skillful tongue movements for chewing. Movements may be uncoordinated or limited in direction or strength. When there is a great deal of food in the mouth, a very small amount of tongue movement will push some food to the side for chewing. Smaller pieces require much more control of movement.
It is important to distinguish between mouth stuffing that is a normal developmental behavior and one that is a compensation for sensorimotor difficulties. Typically developing children have the sensory awareness and the motor skill to remove all food from the mouth at the end of the meal. Children with poor awareness or movement limitations will often leave pieces of food in the mouth after eating. Often parents will find pieces of food pocketed between the gums and the cheeks when they brush their child’s teeth at night. Some children are sure that their mouths are empty when there is still food on the tongue or in the pockets. Many children with difficulties in sensory awareness love foods with strong flavors. Salsa, lemon juice, pickles, and barbecue sauce are often favorites. There may be less mouth stuffing with these high-awareness foods. This can be a clue that the child’s mouth stuffing is related to a sensory difficulty. The child with motor difficulties may push food up into the roof of the mouth where it becomes stuck. When the food later falls down, the child may be surprised and gag or choke on the unexpected mouthful.
Mouth stuffing can be an important diagnostic symptom of a mild-to-moderate oral sensorimotor difficulty. When children resolve their difficulties with oral sensation and perception and improve tongue, lip, and cheek movements in chewing, the mouth stuffing stops. Because it is a compensation, the child no longer needs it as sensorimotor processing improves. It is vitally important to help children clear their mouths after each meal and to become comfortable with regular toothbrushing. When children keep food in their mouths for longer periods of time, they are at a higher risk for tooth decay and aspiration.
While some behaviors are clearly behavioral in nature (sneaking food, for example) others may not be as clear. Food refusal, for example, can be a behavioral problem, but it can also be caused by oral-motor, digestive or sensory problems. Therefore, before treating behavioral feeding problems, oral-motor and digestive problems must be ruled out or addressed first. Next, sensory problems and behavioral problems may need to be distinguished from one another, as sensory problems will probably require some form of sensory stimulation or de-sensitization, while behavioral problems may require other kinds of strategies.
Food Selectivity a Sensory or A Behavioral Feeding Problem. Food selectivity means being very selective about the foods one eats. Food selectivity differs from “pickiness” in degree. Picky eaters usually eat at least one food from all of the food groups. Children with food selectivity, however, often avoid one or more food group entirely. They may eat no fruits or vegetables and/or no meats. They may eat no red foods, or no green foods, or no smooth or wet foods. They may eat only one brand of a particular food and refuse to eat any other brand. They may drink only water and refuse all other beverages. They may eat no more than 3-5 different foods altogether.
Food selectivity is seen in children with a variety of different diagnoses, but it is most commonly seen in children on the autism spectrum. Not every child on the autism spectrum has food selectivity, but a significant sub population of children with autism do have food selectivity.
Is food selectivity a sensory feeding problem or a behavioral feeding problem? Unfortunately, there is no one answer. Each child is different, including children on the autism sprectrum. Some children clearly have sensory reactions to food and need de-sensitization strategies. Other children have more behaviorally based problems and require other kinds of strategies.
Establishing a regular mealtime routine is a key component of most feeding plans. It teaches children a regular routine and also provides opportunities for teaching positive mealtime behaviors. Mealtime routines include serving meals at roughly the same times each day and involving the children in developmentally appropriate tasks, such as: setting the table, bringing food to the table, helping to clear the table, etc. Young children may be prepared for meals by being put into their highchairs and given food or a favorite toy to play with while they wait for mealtime.
Sensory Feeding Problems
These are two commonly used sensory approaches for feeding problems. Please note that they may not be appropriate for all children with sensory feeding problems.
- A sensory diet is a daily routine of sensory experiences. Like a “real” diet, a sensory diet can be offered as a series of sensory “meals” containing specific activities individualized for each child. For feeding, a sensory diet might consist of daily opportunities to play with food. These activities allow children to become familiar with the sight, smell, touch, taste, and texture of foods. Over time, these play experiences may help some children overcome their reluctance to try new foods or food textures.
- Sensory de-sensitization is the process of reducing a child’s reaction to sensory stimuli. For example, if new foods upset a child, we start the de-sensitization process by offering only a tiny amount of a new food at first (1/16 of a teaspoon) and offering it no more than a few times during a meal. These tiny bites of food can be offered in between bites of food that the child likes. Once the child gets used to the routine of having tiny bites of new food a few times during meals, the bites can be gradually made larger and the child can be given more bites in a row. When done slowly and gradually, de-sensitization can be a very effective way to expand the diet.
It is critically important to remember that mouth stuffing is a child’s way of compensating for sensory or motor difficulties. By treating the underlying problem, the child will no longer need to stuff the mouth. Treatment does not address the mouth stuffing itself, but the reasons why the child stuffs. The specifics of treatment will depend upon why the child is stuffing. The following strategies may be incorporated into a child’s program during therapy and at home.
When Stuffing is a Symptom of Poor Sensory Awareness
- Wake up the mouth before the meal, intermittently during the meal, and after the meal with foods that are spicy, crunchy, cold, or carbonated. These 4 sensory inputs can help a child become more aware of the mouth and organize oral movement more effectively. Foods such as pickles, raw carrots, and spicy dips can be included in the meal. Spices can be added to other foods. Cold carbonated mineral water can be sipped between mouthfuls. Add lemon to the mineral water for extra sensory input if the child will accept it. Add ice to other liquids.
- Chew on ice before and during the meal. This alerts the mouth, but simultaneously reduces discomfort from oral sensory defensiveness.
- Use a small table mirror, and have the child visually check the mouth at intervals before taking another bite, and at the end of the meal. Help the child learn what an empty mouth looks like and feels like.
- Use a small vibrator massager before the meal to help build more awareness and movement in the tongue, lips, and cheeks before the meal.
When Stuffing is a Symptom of Poor Oral Movement and Reduced Chewing Skills:
- Use a small vibrator/massager before the meal to build up muscle tone in the cheeks and tongue if the child has low tone in these areas.
- Brush the sides of the tongue when you brush the teeth. This can help get more tongue lateralization which is needed for chewing. Use an electric toothbrush if the child will accept it.
- Provide strong or frequent sensory stimulation to the insides of the cheeks. This can be done with a toothbrush, or by pushing outward on the inside of the cheeks with your fingers. Chewing is a partnership between the tongue and the cheeks. Often poor chewing coordination is caused by cheeks that are inactive.
Strategies for behavioral problems can vary quite a bit. Here are several approaches that are more commonly used. Please note that these may not be appropriate for all children with behavioral feeding problems.
- Break Each Goal Into Very Small Steps. Reward Each Step. Breaking a task into very small, tolerable steps increases the likelihood that a child will be able to succeed at each step. A common strategy is to start with a step the child can already do, or does do regularly. The next time he performs this step, he is praised and rewarded. For example, introducing a tiny bite of new food, as described above in the “Sensory De-sensitization” section, is also a behavioral strategy, because it breaks a goal into very small steps and advances the steps over time. Rewarding children for doing something that we want them to do reinforces the behavior, and makes it more likely that they will do it again the next time we want them to do it. For some children, praise is enough of a reward. For other children, praise alone may not be enough. In these cases, a reward could be a bite of favorite food, a brief opportunity to play with a favorite toy at the table, or watch part of a favorite video, movie, or TV show, listen to favorite music, etc. Every time a child performs a particular step, he is praised and rewarded. The same step may be repeated a number of times over a series of meals, or days, or weeks, until the child can complete the step without difficulty. Then he is guided to the next step in the plan, and so on, until he achieves the final step of the goal.
- Start At Zero. This is a technique more applicable to older children. Children start each day with no toys, games, television, or favorite activities. They must earn each of these items or activities by completing specific steps or modeling certain behaviors.
- Token Economy. This is a technique that works well with some children and adolescents. In this sytem, each time the child completes a step, he earns a star or a check. When he has earned a certain number of stars or checks, he gets a reward (such as renting a favorite movie, a sleepover, etc).
- Resistant and Destructive Children Some children are very resistant to change, no matter how small, and will increase undesirable behaviors when a new routine is begun. Some children may initially cooperate with a new plan and then backtrack or become resistant. A few children have such destructive behaviors that behavioral plans must be very carefully designed to keep children and families safe while still providing appropriate rewards for good behaviors and appropriate discouragements for bad behaviors. Professional guidance is required in all of these cases. Professional help is usually required to determine what kind of feeding problem a child has and what strategies are likely to be most effective. Any child with a persistent feeding problem should be evaluated by a clinician with expertise in feeding problems or by an interdisciplinary feeding team.
- Getting Started With A Feeding Plan. Professional help is usually required before most parents can successfully start feeding plans with their children.
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