The Feeding Continuum: Occupational Therapy & Feeding
August 26, 2019
As children grow and develop so do their eating habits. The number of foods in a child’s diet is expected to increase with developmental age. Many children are described as “Good Eaters” who experience a variety of foods which vary in taste, texture, and presentation. The Good Eaters are interested in and enjoy many different foods. Not all children are Good Eaters; some are Picky Eaters. The “Picky Eater” prefers fewer foods than the Good Eater and has certain aversions to foods. However, the Picky Eater has enough foods in their diet that they maintain health and balance while receiving a variety of nutrients. “Problem Feeders” are on the far end of the continuum; the children in this category have severe aversions that impact their health and well being, and prevent them from eating a balanced diet. Generally, the Problem Feeder demonstrates one or more of the following (Ernsperger & Stegen-Hanson, 2004, p. 4):
- A limited food selection of 10-15 foods, or less
- Refusing one or more food groups
- Aversion when presented with novel foods
- Food jags; requires the same food to be presented at each meal
- Diagnosis of a developmental delay
Frequently the foods a Problem Feeder accepts are similar in presentation, texture, and/or taste. Some Problem Feeders have a fear of new foods (neophobia). This is developmentally appropriate for two-to-three year olds, however, Problem Feeders may demonstrate an extreme reaction including tantrums, gagging, or anxiety. Food jags in Problem Feeders are exhibited by requesting particular food for a period of time, only to later outgrow that food and refuse it in the future. Many Problem Feeders also experience a health-related disorder including, but not limited to, neuromuscular disorders, developmental delays, and medical diseases. These may interfere with chewing, swallowing, digestion, and/or sensory input.
Oral Motor Abilities
Oral motor abilities include the muscle movements of the mouth, lips, tongue, cheeks, and jaw. These muscles work together to suck, bite, crunch, chew, and lick. Oral motor skills are essential to effective eating and overall functioning. The child who has oral motor deficits may also demonstrate any of the following:
- Low muscle tone
- Poor body coordination and balance
- Poor postural control
- Difficulty crossing midline and using both sides of the body together
- Poor hand-eye coordination
- Poor body awareness
- Difficulty with behavior management
- Struggles with transitions
- Problems with speech and language development
Without appropriate oral motor skills, a child may frequently gag or choke, drool, struggle to keep food down, poorly transition between foods, have difficulty sucking, chewing, and swallowing, and/or have picky eating habits. All children develop these skills at their own rate, but some may plateau in development and require intervention from an Occupational Therapist and/or Speech-Language Pathologist. The following is an overview of oral motor skill acquisition in semi-chronological order:
- Jaw, tongue, and lips move as one unit
- Munching movement of the jaw
- Transfer foods from front to back of the tongue to swallow
- Lips close tightly at the corners
- Jaw movements separate from tongue and lip activity
- Controlled bite
- Sucking through a straw
- Diagonal movements of the jaw during chewing
- Cheeks coordinate with the tongue to keep food on teeth
- Minimal loss of food during chewing
- Swallowing occurs with lip closure and an elevated tongue-tip position
- Tongue cleans the lips
- Tongue cleans the area between gums and cheeks
- Grading of jaw opening for different food thickness
- Circular rotary chewing
For specifics on oral motor development, consult with an OT or SLP who specializes in feeding and eating.
Types of Foods
Ernsperger & Stegen-Hanson (2004, p. 29)
Thin Puree: food forms a thin paste or thin liquid (pudding, applesauce)
Thick puree or blended: food forms a thicker consistency that doesn’t have lumps (blended foods)
Mashed lumpy: foods form a heavy bolus (mashed potatoes, bananas)
Ground: ground food, not blended, ⅛ – ¼” in size (crumbled meat, scrambled eggs, cottage cheese)
Chopped: ¼ – ½” in size (fruit cocktail)
Regular: cut up food or leave it whole (all foods)
Sensory vs Motor Problems
Problem feeding may result from either sensory or motor problems, or both. Problem feeders who have sensory-based deficits struggle to eat because their sensory systems reject the eating and drinking process. The sensory system consists of proprioception, vestibular, tactile, gustatory, olfactory, vision, and auditory. For a description of these systems, see “Common Occupational Therapy Terms You Should Know”. Deficits in sensory processing may result in difficulty with holding utensils, posture, chewing, muscle tone, attention to movement, avoiding or seeking movement, disliking textures, mouthing items, disliking being messy, preferring plain foods, shielding eyes, easily fatiguing, along with many other signs. Children with motor-based concerns may demonstrate deficits in muscle tone and movement patterns. In addition to these, they may struggle with sucking, swallowing, and breathing. They may have difficulty coordinating and timing mouth and body movements. Other reasons for problem feeding may include reflux and gastrointestinal problems. Possible indicators of oral-motor dysfunction include: abnormal sucking pattern, nasal reflex, aspiration, gagging, drooling, tooth grinding, limited upper-lip movement, immature feeding skills (pp. 88-89).
Creating a Supportive Environment
Each Problem Feeder requires a treatment plan specific to their individual needs. However, these general goals are important for each child: creating a safe and positive mealtime environment, increase the child’s participation in all mealtime steps, improving physical needs and oral-motor development, provide multisensory exposure to new foods, respect the child’s response to eating, and expand the child’s food collection to create a healthy diet (pp. 101-102). It is important to schedule meals at a consistent time in a predictable location. Creating a supportive setting includes learning about new foods, designing appropriate portions, and offering at least one preferred food at every meal time. Supportive mealtime behaviors include respecting the child and not invading their mouth without permission, demonstrating eating techniques, using positive language, and discussing the taste, texture, and smell of new foods. These are only a few suggestions, please see an Occupational Therapist for specific recommendations to meet the needs of your child.
Feeding therapy should be playful, nurturing, and implemented in a non-threatening setting. The child should have fun and should not feel coerced into eating. Normal Eaters and siblings can be used for support and as positive role models for appropriate eating. Many opportunities should be provided throughout the day to learn about new foods. Children learn to eat through sensory experiences with food. These include acceptance, touch, smell, taste, and eating (p. 172). Acceptance includes tolerating the presence of new foods and reducing negative behaviors that surround feeding and eating. This stage includes plenty of time to play with new foods. Touching foods helps the child develop an understanding of new foods without needing to bring them to the face. Smelling foods allows Problem Feeders to smell the food and slowly bring it closer to the mouth. The sense of smell is closely related to successful eating. The child is then required to begin to taste new foods to increase awareness. Finally, the child is asked to eat new foods without anxiety or negative behaviors. Remember, not all children like the same foods. Everyone has their preferences, but it is important to experience a variety of foods and keep a balanced diet to promote development.
All information provided in this article is either personal knowledge or was retrieved from Ernsperger, L. & Stegen-Hanson, T. (2004). Just take a bite: Easy, effective answers to food aversions and eating challenges. Arlington, TX: Future Horizons, inc.
About the Author: Bailey Palladino, MS, OTRL is a licensed occupational therapist specializing in autism spectrum disorders, ADHD, and developmental delay. She is a member of the clinical team at BRAINS in Grand Rapids, Michigan. Read more about Bailey click here.