H.M. Systems Inc.

Feeding Difficulties with children

Are Feeding Difficulties Related to Oral Motor, Sensory or Behavioral Issues? By Alice Y. Heebner, OTR/L

This Blog is on possible causes for feeding difficulties, with the focus being on improving oral motor hypersensitivities.

Many therapists and parents struggle with children and their respective feeding difficulties. There may be a variety of reasons which could include one of the following: oral motor, sensory, behavior or a combination of all of the above mentioned.

A typically developing child will demonstrate controlled, efficient, rhythmical, as well as sufficient strength and endurance in oral motor skills during feeding. The jaw should be opening and closing volitionally. The jaw should also be demonstrating a variety of rotary chew (e.g. diagonal and rotary) as the child progresses in his feeding skills. The lips should be able to close and provide a seal around a nipple on a bottle, rounding into a circle on a straw, or spreading into a horizontal line on a fork or spoon. The tongue should be able to cup, suckle, suck, protrude, retract, lateralize and elevate. The cheeks should be able to protrude, retract and compress. The child that has oral motor challenges can work on different strategies with an occupational therapist, speech therapist, nutritionist and overall feeding team to improve oral motor functional skills.

There have been children that demonstrate normal functioning oral motor skills (tongue, lips, cheeks, jaw movement), but are aversive to having any food touch their lips, mouth, face or body. This is most likely related to sensory issues that can at times turn into behavioral issues.

Behavioral issues may most likely stem from the child’s emotional experiences with his/her feeding as an infant. If the child has had a good “normal” experience (e.g. the child has had an appropriate appetite in the past, has typical oral motor skills, has demonstrated hunger and desire for food, and overall pleasure from the intake of food), then there most likely will not be any “behavioral issues”. On the other hand, if the child has had a negative experience in the past with food/feeding (e.g. poor appetite, gagging, reflux, forced/coerced feeding from caregiver to increase caloric intake, etc.), then he/she will most likely learn to dislike any association with food intake.

The following are some suggestions on different strategies to reduce oral motor hypersensitivity as outlined in “The Get-Permission Approach to Sensory Mealtime Challenges” by Marsha Dunn Klein (2009).

It is important to remember that “mealtime” include some of the following factors: nourishment, communication, socialization, sensory exploration, celebrations, family time, and skill mastery. Children that demonstrate sensory challenges in eating/feeding may be due to their negative emotional experiences in the past with an oral motor task. These children may not even want to be around food. In order to begin familiarizing the child with food and decrease his/her aversion to food, whether it is tactile, olfactory, or even visual, give the child different opportunities to be around food. The child can be encouraged to participate in the following: play with plastic food toys/oven/cooking utensils, play with cards that have pictures of food on it, plan a menu, grocery shop, set the table, clear the plates after dinner, wash dishes, serve food with fingers or utensils, pour drinks, etc.

For children who have sensory challenges with increased textures, the following are some suggestions that can be implemented during mealtimes or snack times: stretching, dipping, and crumbing. The strategies can and many times may overlap.

Stretching involves slowly progressing from a familiar to an unfamiliar gradually. A familiar utensil, flavor, texture, shape, temperature or color can all be “stretched”. A familiar spoon can be “dipped” into a pureed, liquid, nectar, or lumpy texture so the child can be exposed to different textures. A familiar flavor can be stretched by “dipping” different “utensils” (e.g. child’s finger, toy, different textured spoon/toy, vibrating brush, etc.) into the flavored food/liquid texture. Stretching texture involves going from liquid to solids, vice versa, or a combination of some of the following: liquid to puree, nectar to puree, smooth puree to textured puree, puree to soft lumpy puree, puree to predictable lumps, puree to unpredictable lumps, wet to dry, crumbs, bitable meltables, and solids.

The above paragraph mentioned some of the different ways that can be stretched as well as be used in “Dipping”. The child can also use a familiar dipper and “dip” it into different dips (e.g. fruit purees, veggie purees, cream cheese, sour cream, whip cream, jam/jelly, guacamole, hummus, refried/blended beans, blended/pureed soups, cheese sauce, or salad dressings). A familiar dip can be explored by using different dippers (e.g. spoons/forks, straws cut in half, coffee stirrers, swizzle sticks, chopsticks, pretzels, crackers, cookies, strips of raw or cooked veggies, or strips of fruit).

“Crumbing” can help sensitive and cautious children make food texture transitions. The variety of ways that crumbs can be prepared in different consistencies include: fine to rough, smooth to sharper, even to uneven, and meltable to more lingering. Crumbs can be used in different ways: mixed with pureed foods, sprinkled on the puree so they touch the palate, a spoonful of familiar puree can be dipped in a pile of crumbs on the side of the spoon so the crumbs enter one side of the mouth, then present it to different sides or areas of the mouth as the child makes appropriate adaptive responses. Using different flavored crumbs will also expose the child to increased sensation (e.g. cheerios, saltine crackers, Ritz crackers, rice crackers, fruit loops, cheetos, or gingersnap cookies). To stretch crumbing, a spoon can be dipped into a favorite wet food, then re-dipped into a pile of crumbs. After the child demonstrates his/her enjoyment of a certain crumb, a new wet flavor can be introduced.

There are many other strategies that have not been covered in today’s blog, but can be accessed by consulting with an occupational therapist, speech therapist, and/or feeding team.