Many children with feeding difficulty have aversive feeding behaviors or learned refusal patterns around the act of eating or feeding. I often tell my students that if a child doesn’t want to eat, you can’t make them. By the time children come to our feeding team, many caregivers have tried multiple ways to get there kids to eat. Usually they have tried force feeding and/or letting the child get very hungry. Neither of these alone will fix a feeding problem which are typically multifactorial in nature.
Children refuse foods in many different ways. Here is a list of some of the most common aversive feeding behaviors:
- Poor mouth opening for the spoon.
- Refusing foods by turning away, blocking the spoon, covering their mouth.
- Irritability and tantrums during feeding attempts, saying “no”.
- Expelling foods.
- Drinking instead of eating.
- Using delay tactics to stall the next bite.
- Refusal to sit in a highchair or at the table.
- Accepting only specific foods by type, texture, or brand.
For this post, I am going to concentrate on the first one, poor mouth opening for the spoon. This is very common with our food refusers. These are the kids that look like they are accepting the bite and then more than half of the puree comes off the spoon on the way into the mouth. I have also noticed that when caregivers are feeding a child who is hard to feed, they develop maladaptive feeding techniques such as dumping the food into the mouth, scraping the spoon off the upper gums, or loading the spoon (because they may only get a few bites) and shoving what they can into the oral cavity.
Let me tell you about a little guy I used to work with. I can remember him sitting in the highchair one day and we were working on acceptance of the dry spoon. Sometimes we call this “spoon game”. The idea is that we want to start where the child can be successful and for many kids that is without food. We are going to work on shaping behavior toward oral feeding and one of the starting places is having a child accept the spoon.
And I mean acceptance of the whole spoon– the goal is
- mouth opens with tongue down on the floor of the mouth
- therapist places spoon on child’s tongue with slight pressure
- child closes lips
- spoon comes out
During this particular therapy session, the child who I will call Charlie was sitting in the highchair. He was a little under the age of 2. I presented the spoon with a verbal cue to “open” and Charlie would respond by opening his mouth a crack, enough to let the tip of the spoon through his lips but not into his mouth. I tried multiple times with toy reward, verbal cueing, and visually showing him but Charlie continued opening his mouth only a crack. After a short period, we let him get down from the highchair, while I talked with his mother. Wouldn’t you know Charlie walked right up to me, tapped my leg, looked at me and opened his mouth as wide as he could. Then walked away pleased with himself.
I am happy to report that after feeding therapy, Charlie is now a good eater and is eating table foods well and has never looked back. Those days of poor mouth opening are long behind him.
So why do I persist on getting full acceptance of the spoon?
For several reasons:
- To successfully eat from a spoon you must be able to accept the spoon in your mouth. I have dubbed this teaching “spoon technique”. For some of our kids the decreased mouth opening is a behavioral response not a physical one.
- If we can establish acceptance of the spoon, it opens up the ability to work on many things: decreasing a humped or retracted tongue, lateral placement of the puree as a pre-chewing exercise, introducing new flavors and textures, and lip closure.
So how do we get mouth opening?
- Child should be positioned in a highchair or supported seat.
- Start with a dry or empty maroon or infant size flat spoon.
- Caregiver or therapist feeds the child, present the spoon and say “open”
- If the child does not open wide enough, I might say “big open’ and I model an open mouth posture, sometimes I add a sound cue “ah”.
- If the child still is not opening, then I use the spoon on the upper lip and tap upwards on the lip while I provide jaw stability with my other hand. Most kids will open with this technique.
- Then I place the spoon on their tongue with slight pressure before coming out of the mouth with the child’s lip closure.
- I also consistently use reinforcement (toys, verbal praise,etc) when the child opens so they are motivated to do it again.
Usually, I will not move onto to purees until I get good consistent opening for the dry spoon. The exception is some kids open better if there is something on the spoon so I might use a dip spoon in water, juice, or a thin puree. If using food, I stay at a dip level until we have consistent spoon technique of good opening.
Home practice: I teach parents to use this technique and I ask them to practice a certain number of times each day at home. Then at the next session, I ask the parents to feed and to show me how it is going. If it is going well, we move up to dips or small bite volumes of smooth puree.