Feeding

Feeding as an Occupation

• Includes feeding, eating, swallowing, & mealtime preparation

• Involves medical, sensory, motor, behavioral, positioning, & environmental influences

• Every family completes mealtimes differently - includes learning, fine motor skills, socialization, social-emotional, sharing, and togetherness 

• Self-feeding:

• Eating: using oral-motor skills to create a bolus, pushing to the throat, and triggering the swallowing reflex 

• Modified Barium Swallow: https://www.youtube.com/watch?v=xu_YYOAlZEw 

Conditions Associated with Feeding Issues

• Prematurity 

• Neuromuscular abnormalities

• Structural malformations (e.g., cleft lip/palate, etc.)

• GI Issues (GERD, EoE, etc.)

  • Eosinophilic Esophagitis: chronic inflammation of the esophagus

  • GERD: gastroesophageal reflux disease

• Visual impairments

• Tracheostomies

• ASD

• Food allergies

• Many of these conditions can lead to negative associations with eating, feeding, and mealtime routines, which exacerbate the issue

Phases of Swallowing:

• Oral Preparatory Phase: jaw, lips, tongue, teeth, cheeks, & palate manipulate food to create a bolus

• Oral Phase: tongue elevates against the hard palate to move the bolus posteriorly

• Pharyngeal Phase: Swallow is triggered, epiglottis covers airway, and the esophageal sphincter opens

• Esophageal Phase: bolus travels through the esophagus and enters the stomach

6 Steps to Chew & Swallow

• Front bite, food on tip of tongue

• Tongue tip lateralization to move to molars

• Chew on back molars

• Keep it in place with tongue and cheek

• Food travels to the back corner pocket across the tongue

• Swallow

Development of Eating Skills

 ~0-12 Months~

• 0-3 Months:

  • Reflexive patterns (rooting, sucking)

  • Establishing sensory, social, and bonding during mealtimes

  • Small oral cavity; suck, swallow, breathe; Epiglottis covers airway so safe to feed in reclined position

• 3-6 Months:

  • Improved head/neck control > upright seating for feeding (postural & motor control develops)

  • Aspiration is at higher risk, so upright feeding occurs

  • Texture exploration, pureed food exploration; oral exploration (babies begin to mouth objects/body parts)

  • The oral cavity becomes larger

• 6-8 Months:

  • Teeth erupt, lots of mouthing

  • Spoon feedings with purees > meltable finger foods

  • May still use a suck to transport food back

• 8-12 Months: 

  • Meltable finger foods > mashed table foods > soft foods

  • Munching > vertical chew > diagonal chew

  • Munching: Symmetrical up and down; jaw and tongue move together

  • Vertical chew: Jaw and tongue separate; tongue lateralization emerges

  • Diagonal chew:

  • Rotary chew: Diagonal chew with tongue lateralization 

~12-24 Months~

• 12 Months:

  • Cup drinking begins (cup, straw, sippy cups, etc.)

  • Occasional tongue protrusion with swallowing

  • Soft foods: rotary chew emerges; bite with front teeth

  • Begin to transport food to both sides of the mouth, food and liquid loss

• 18 Months:

  • Cup drinking is more mature, with less liquid loss

  • Jaw stable, raw fruit, cooked meats

• 24 Months:

  • Mature cup drinking

  • Most table food, careful of choking hazards

Developmental Food Continuum

• Must complete one before moving to the next (e.g., cannot eat soft cubes with purees without eating soft cubes and purees separately

1. Breast/bottle

2. Thin Baby Cereals

3. Stage 1 - Thin purees

4. Stage 2 - Thicker, smooth purees

5. Soft mashed table foods; Thick, smooth purees

• At 8 months, develop the tongue wave to pull food backwards

6. Hard munchables - feed tool, not actual eating

• develops FULL tongue lateralization

• Not for consumption - long and hard so that you can't bite off

• Moves the child's gag reflex backwards

• Teaches lateral movements of the tongue

• Jaw strengthening*

• Kinesthetic awareness to entire mouth

• Good prep for toothbrushing

• Traverse Tongue Reflex - When you put a food in your mouth, your tongue automatically goes to it (no tongue tip lateralization, but more a reflex to prevent choking)

• Examples: Carrot stick, spoon handle, chewy tube, jicama, dried papaya, frozen French toast stick, lollypop

7. Meltable hard solids

• develops tongue TIP lateralization 

8. Soft cubes

• Soft exterior but holds shape, needs tongue or munching pattern to break down

• Avocado, soup ingredients, banana

9. Soft mechanicals (single)

• develops diagonal chew into rotary chew, jaw shift, grinding, and mastication

• Soft exterior but holds shape, needs munching/grind pressure to break apart

• Lunch meats, pasta, cooked eggs, white bread no crust

10. Stage 3 - soft cubes mixed with purees; soft mechanicals mixed

• Mac and cheese, microwave kids' meals, fish sticks, chicken nuggets

11. Soft table foods

12. Hard mechanicals

• Needs grinding/rotary chew to break apart

• Food scatters in the mouth

• Cheerios, saltines, fritos, steak, fruit leathers

Evaluation

• Interview: in-depth with family concerns, feeding practices/routines, cultural norms, development & feeding history

• Records review: family history, developmental history, weight, height, BMI curve, diagnoses

• Observation of mealtime: structures, oral mechanisms, oral motor

• Tone, neuromuscular status, sensory processing, general development

• Additional diagnostic, medical assessments: MBSS, FEES, upper GI series, endoscopy

  • MBSS = modified barium swallow study 

  • AKA videofluroscopic swallow study = radiographic assessment to identify ASPIRATION.  

    • Looks at oral, pharyngeal, and upper esophageal function for feeding and swallowing

  • FEES = Fiberoptic endoscopic evaluation of swallowing = uses flexible endoscope with light and camera into the nostril and down throat. Camera videos SWALLOW FUNCTION as the child eats/drinks

  • Upper GI: Upper gastrointestinal series to assess the presence of GERD

  • Endoscopy: Endoscope through nose to see the esophagus stomach, and duodenum

Intervention

General

• Collaborate with medical professionals and family

• Multidisciplinary approach

• Family training

• Periodic family mealtime routine observations to ensure carryover and fidelity

• Consider child factors, family patterns, environmental context, activity demands

• Prioritize nutritional needs/status

• WEAR GLOVES!

• Consider: choking risks, dietary restrictions, allergies, family culture, medical concerns

Environmental Adaptation

• Consistency: Location, materials, positioning

  • Location: Not walking around and grazing

• Timing

  • Mealtimes are established so that children can experience hunger between mealtimes and actually eat what would be considered the more nutritious food

  • Also longer for oral motor issues, shorter and more frequent for GERD or other weaknesses (e.g.: dysphagia).  Try not to go longer than 40 minutes

• Environmental stimulation

  • distracting vs not; calming vs alerting

  • depends on the child what is best!  Some may need a distraction or an alerting environment!

• Order

Modification to Food/Liquid

• Consistency/Thickness

  • Thickened liquids are easier to control

  • Can use for cup drinking to slow things down or also use it for oral motor or oral sensory differences

  • Foods can be pureed into thickened foods.

  • Consistencies = thin, nectar, honey

  • Carbonated liquids are seen to be better than thin liquids for aspiration issues.  Can be an alternative to thick liquids

• Size/Amount

• Temperature

  • Especially impactful for kids with sensory issues (hot v. cold aversions)

• Flavor

  • consistency of flavors (e.g., one blueberry may be tarter than another, whereas a cracker would generally taste the same across each item)

Positioning

• Child should be in 90-90-90

• Facilitates

  • improved fine motor and self-feeding

  • sense of security

  • better ROM in jaw

  • increased respiratory function

• Proximal support and trunk stability

• Head & neck positioning

• Jaw mobility

• Tongue & lip control/mobility

Adaptive Equipment

• Spoons & forks

  • Consider size/type 

  • shallow for reduced lip closure

  • rubberized for those who use bite for jaw stability

  • textured or chilled for low tone and sensory discrimination issues

  • built up handles/universal cuff

• Straws

  • length/width, smaller requires less suction

  • one way valve; bear with squeeze

  • Nosy cup: neutral head position

• Cups

  • Sippy cups - beware… affects child’s oral motor control and swallowing. - Instead use a recessed lid

• Plates/Bowls

Self-Feeding

• Can practice during a natural mealtime or during therapy mealtime

• Backwards chaining - child does the last step and then backs off according to the AA*

• Jaw strength/stability & lip closure

• Consider: 

  • Positioning - FIRST

  • Raised tables/trays

  • Dycem

  • Equipment

Bottle to Cup

• Work on jaw strength/stability, lip closure, tongue movements, & oral sensitivity

• Nosy cups

• Cups with recessed lids

• Cups w/ straws

• Sippy cups

• Thickened liquids

• Physical prompts & jaw support

• *Watch for biting cup or pushing to corner of lips & using tongue for support

Oral Motor Impairments

• Jaw strength/stability

• Lip closure

• Tonic bite

  • *Optimal physical positioning and slightly flexed head helps with tonic bite 

• Tongue thrust

  • Tongue lateralization activities for tongue thrust

  • Placement of food to sides of mouth

  • *Optimal physical positioning and slightly flexed head helps with tongue thrust

• Back/forth movements of tongue

  • Silly faces in mirror

  • Licking games

  • Stroke NUK to inside cheek and sides of tongue

• Lip & cheek abnormal tone - impacts lip closure

  • Hypertonic– lip and cheek stretches, whistles

  • Hypotonic-vibration, quick massage

Cleft Lip & Cleft Palate

• Lack of closure between oral & nasal cavities to create suction for bottle and breast feeding & frequent leaking from nose

• Solutions:

  • Upright positioning (>60 degrees) 

  • Physical cheek and lip support

  • Specialized bottles activated with up/down movements (not suction)

  • Bottles with longer nipple to go posterior to the cleft

  • Scar management post-surgery

  • Activities to address hypersensitivity post-surgery

Non-oral to Oral Feeding

• G tubes & NG tubes

• Going to need to continue oral sensory exploration, oral motor development, social mealtime experiences without non-nutritive items/games

  • Whistles, bubbles, kisses, sensory stim around mouth

• Go slow as child is medically cleared for food exploration

  • Once can have food, dip finger, spoon or toys into food; puree foods, etc.

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