By Kaye Koelker, CCC-SLP, Minneapolis, MN
The families I work with dream of sitting down to enjoy a meal together. That’s usually not what they experience. I work with infants, children and teens with oral motor difficulties that make eating a challenge. Some families I work with find meals so stressful that they avoid them completely. It doesn’t have to be that way. I’d like to share some case studies of common problems that can be overcome with oral motor therapy.
Starting Out Right
In the hospital, Amanda’s parents got a lot of support from nurses and other feeding specialists. On their own at home, they were concerned that feedings were not going as well as they should and they came for a feeding assessment with one-month-old Amanda. When her parents held her in positions where their bodies felt more stable, it was easier for Amanda to eat. Using a Boppy pillow allowed the parents to provide support through the entire feeding, and they were able to give Amanda the jaw and lip support she needed to effectively nipple. With Amanda’s low muscle tone, a feeding sling helped her parents provide better support at a 45-degree position, which also helped to move fluid effectively through the small eustachian tubes in her ears. If Amanda was not fed with her ear above her mouth, fluid build-up could result in otitis media. (An older infant can be fed at angles between 45-90 degrees.) A third position, the football hold, left one hand free to provide jaw and cheek support while feeding. With better stability for parents and baby, one week later Amanda’s eating had improved — a relief to everyone.
Three-month old Ian arrived in my office with his parents and a bag full of bottles and nipples. His parents were confused about which one worked best because Ian lost liquid out of his mouth with every single one. While his parents supported Ian’s body, they were not supporting his mouth and cheeks. We evaluated each bottle and nipple with a position change and added jaw, cheek and/or lip support to see which one would be the most successful. The Nuk nipple allowed Ian to get nutrition, but I was concerned that the tongue stayed too flat and he wasn’t able to get a strong suckle. The Avent bottle allowed him to be fed upright due to the design of the bottle but his suckle was weak and he continued to lose liquid out of the corners of his mouth. The Haberman allowed his parents to control the liquid flow, but it was not the best choice for their budget. Ian did best on the Playtex nipple, which was short and narrow, similar to the breast. They squeezed the bag to get rid of any excess air and this allowed a little bit of liquid to flow into Ian’s mouth to initiate his suckle. Ian was often sleepy while feeding, but seemed more alert when using this bottle and had a stronger lip seal. This made feedings less stressful.
Tricky, Picky Toddler
His parents thought three-year-old Carter ate junk food because he was stubborn. They did not know that Carter’s pickiness was related to oral motor dysfunction. Low muscle tone, poor trunk control and a slouching body did not give Carter the stable postural support necessary for more refined oral movements. He took one sip at a time from a cup, while biting on the rim, and struggled with his tongue when using a straw. A weak bite and up-down munching pattern with limited lateral (side-to-side) tongue movement meant he loved Cheetos, cookies, cereal, and French fries and would not eat vegetables, meat or fruit. Carter chewed with his side teeth rather than his back molars and his mouth was open. He had poor sensory awareness and imprecise oral movement, stuffing food into his mouth, chewing very little and unaware of what was left on his tongue after he swallowed.
Carter’s therapy plan required exercises to address low postural tone, instability and position; and difficulties with oral movement for feeding and response to sensory input. Carter now uses a chair with side and foot support, sitting at a 90-degree angle at the hips, knees and ankles and responds to verbal cues to “sit up tall.” The table is the right height for his hands to rest without elevating his shoulders and he can look family members in the eye without hyper-extending his neck.
Carter’s daily exercises improved movement for feeding and improved his responses to sensory input. At least once a day, Carter had an oral massage or did Beckman facilitation stretches. To improve jaw, lip, tongue and cheek strength and mobility, we used oral motor tools, such as Chew Tubes, ARK Grabbers and a Z-vibe, followed by a food (following SRJ hierarchies and chewing techniques learned at Lori Overland’s feeding classes). We added a sensory component by dipping the tools in ice chips and water or tart lemonade, which stimulated Carter’s tongue to move more. Now, Carter can clear food from his molars, gums and hard palate.
Food shape and position in the mouth gave Carter more control to work on tongue retraction, lip closure and jaw grading. Cubes of foods were placed onto his molars using a small fork in an upside down position or cut into julienne strips and eaten in consecutive bites on his molars. We alternated bites between one veggie stick chip and two veggie stick chips stacked to work on a natural progression of jaw grading and bite control. Carter’s sensory and motor skills improved to handle larger, chewy foods such as bread sticks, pretzel rods, veggie pizza cut into strips, dried apricots and more. An added plus of his new fiber-filled diet is less constipation.
Teaching New Tricks to Teens
Thirteen-year-old Tim’s mother called me after he refused to eat food — yet again — at a party they attended. His parents were at a loss as this was a typical pattern for Tim in the community and at home. He would not eat at a restaurant that did not have hamburgers or pizza on the menu. Tim was very social and enjoyed hanging out with friends despite refusing to eat at their homes. He was also slightly overweight, despite being active in sports. His parents were aware of nutritional guidelines for teens with Down syndrome and monitored his caloric intake the best they could. They wanted him to eat more fiber, vitamins and minerals with fewer carbohydrates — but he refused to eat those foods.
His parents wanted to put him on a more nutritious diet, but that was not possible because he ate so few foods. He ate soft to semi-soft processed foods including pizza, hot dogs on a wheat bun dipped in ketchup, hamburgers, Arby’s roast beef sandwiches, instant oatmeal, Jimmy Dean croissant breakfast sandwiches, and strawberry custard style Yoplait yogurt. These foods, except for pizza and hamburgers, were also limited to specific brands. Raspberries or oranges, and kiwi, if cut into round pieces, were his only fruits. Vegetables were not even an option yet. Tim could not eat more than one food from the same plate and had to change forks for different foods or have his parents wipe off the utensil.
Tim did not have the oral motor skills to eat crunchy foods (carrots/celery) or steak, and skins on fruits and vegetables got caught in his teeth. He stuffed his mouth full (putting him at risk for choking), had decreased sensitivity and awareness within his mouth, ate with his lips open, protruded his tongue when swallowing, had a weak bite, preferred to eat on his left side and suckled when drinking from a straw.
In therapy each week, Tim focused on improving his oral motor skills and expanding his diet by changing the way familiar foods were presented. Therapy was organized, systematic and predictable to avoid sensory overload and failure. Visual supports helped him understand all the steps needed to chew and swallow one bite of food. A great challenge was carryover into the home, so his mother, personal care assistant or siblings participated in each therapy session.
The first challenge was to get Tim to eat the same food in a different shape. For example, Tim balked at eating kiwi cut into rectangles rather than circles or eating square crackers instead of rectangles. This was eye opening for his parents, who realized it was not just stubbornness at work.
When Tim got braces, he still managed to consistently make small diet advances. Foods were presented at least 10 different times with incremental changes in sensory properties. First, we changed the temperature of familiar foods and added one non-preferred food each session that matched in all other properties. Veggie stick chips with three different colors but all the same characteristics were introduced at the very beginning. These could be paired with foods that were cut into julienne slices with orange, white or green colors. Presented foods were also from different food groups (fruit, vegetable, meat/protein, hard munchables and meltables). The taste changed, but always stayed close to home base. By changing one sensory component at a time, we identified which foods or properties had the most impact. Not until Tim developed the necessary motor skills did we change the texture. A sample food day for therapy would look like this: Club cracker with peanut butter, toast with peanut butter cut into rectangular-shaped strips. Next vegetables were cut into strips mixed in with veggie stick chips: white veggie stick, jicama sticks, green veggie stick, green pepper strips, orange pepper strips, orange veggie stick, orange wedge and cantaloupe melon.
At 15, Tim eats a variety of foods and snacks but continued food jags require his parents to implement strategies learned throughout the last year. Transitioning skills learned in therapy to home is still a challenge. We recently started eating in restaurants to move the learned skills to another environment and then transition skills into the home. Since Tim is older, he responds to charts for tracking and asks family members to play his taste test game. When blindfolded, Tim cannot distinguish between different flavors of unseen foods — especially those that are similar, such as ham, turkey, chicken, roast beef). Familiar foods were always paired with non-preferred and Tim began to eat pasta in different forms using pepperoni added to a cold pasta dish (pepperoni being the preferred food). Tim started eating a small rotini noodle rolled in pepperoni and eventually he would eat cold pasta without pepperoni. Tim now eats six different pasta noodles.
Tim now is able to drink a shake with his Dad at the gym and eat crackers with peanut butter as a snack. Though still a challenge, he enjoys many different fruits and some vegetables, both raw and cooked. He drinks V-8 Fusion and Pomegranate juice and adds veggies to pizza or tortillas with meats. Tim likes to make snacks and meals together in therapy and with family and friends. Tim’s family is happy to enjoy social mealtimes at a variety of restaurants. Tim has made excellent progress and continues to benefit from oral motor exercises and weekly feeding therapy. Now when Tim tries something new, he wants to make sure I hear about it!
As you can see, oral motor and feeding therapy improved the quality of life for Amanda, Ian, Carter, Tim and their families. As clinicians, we need to figure out and address the underlying issues affecting your child’s feeding habits so that each child may continue to develop and advance their feeding skills and learn to enjoy family mealtimes.
Pre-Feeding Skills 2nd Edition, Suzanne Evans Morris, PhD, CCC-SLP, Marsha Dunn Klein, MED, OTR/L
Lori Overland, Developing Oral-Motor and Feeding Skills in the Down Syndrome Population (one day course available through Talk Tools)
Lori Overland, Feeding Therapy: A Sensory-Motor Approach (two-day course available through Talk Tools)
Diane Chapman Bahr, Oral Motor Assessment and Treatment; Ages and Stages
Sara Rosenfeld Johnson, MS CCC-SLP, Assessment and Treatment of the Jaw
Editor’s note: Kaye Koelker Baumgardner, MS CCC-SLP, is co-founder of Minnetonka Pediatric Therapy Center in Minnetonka, MN, and has worked with hundreds of families to address feeding challenges and oral motor difficulties in infants, children and teens with Down syndrome. She may be reached at Kaye.K@minnetonkatherapy.com.