I’ll give you the answer first: a child’s diet texture should be appropriate for their oral skill level. Sounds so obvious right?
I’ve seen this scenario many times… a child is referred for a feeding evaluation because of poor eating (not eating enough), choking with meals, pocketing or expelling foods, or having prolonged meal time. Parents are at their wits end, they don’t know how to get the child eating more and now the pediatrician is concerned because the child is falling off the growth curve.
Sometimes, the problem is simply poor chewing. Every feeding evaluation should include a thorough history, an oral motor exam and an observation of the child’s feeding with a variety of liquids and solids of different consistency.
- First: rule out GI causes of poor eating and painful swallow – this would include gatroesophageal reflux, constipation, food allergy/intolerance, motility issues, etc.Additional info needed if caregivers report coughing or choking during the meal:
- For choking- ask if the child is choking on liquids or solids?
- If the child is choking on liquids, this may be more indicative of an oral-pharyngeal dysphagia.
- If the child is choking on solids, it may be either a GI issue (solid food dysphagia is typically associated with GI issues especially in adults) or the problem may be that the child is swallowing food whole because of poor chewing.
During the feeding observation, carefully assess the child’s oral motor pattern with liquids, purees, and solids. For this post, we will concentrate on the solid foods.
Many caregivers are feeding age appropriate foods not realizing that the child is stuck in an immature oral motor pattern such as a sucking or suckling pattern. These are children who accept a solid such as a chicken nugget, pasta, or a peanut butter and jelly sandwich and suck on it or tongue mash it. One clue is if the toddler accepts the solid into his mouth and then closes his mouth to manipulate it. Until a child is taught to “close their mouth” during chewing they will chew with their mouth open. When toddlers chew, you should see the food moving from side to side in a lateral transfer pattern. Caregivers will often report that the child takes a long time to eat, or they hold food, expel food or even choke on food.
For children who are stuck in a sucking pattern, they may want solids but do not have the skills to adequately manipulate them. They may start off with a vertical or open mouth chewing pattern with lateral transfer but then move back to sucking. Some back and forth is typical, however, for our kids with oral motor delay (low tone, fatigue, etc.), it can be difficult and detrimental for the child to attempt to consume a full meal of solids. At this point, they can only expel the solid, hold it, or swallow it whole causing choking.
Recommendations: For these children, we want to make the recommendation that they go back to a purees (real food pureed if possible). If the child has emerging chewing skills they might be able to have success with a meal of 25-50% chewables and the rest pureed to account for fatigue or we could add a high calorie drink to assist with meeting their caloric need while decreasing the need for chewing.
Their diet textures should match their oral motor abilities! In a few cases, especially with older children who are sucking their solids, I have educated parents on the risk of choking. Not too long ago I observed a child swallow a piece of sausage whole and then struggle to swallow it. I strongly recommended that this child not be given any solids that did not melt.
Can you imagine eating tough steak 3 times a day? Your mouth would be tired and it would not be motivating to continue. And it would only take 1 serious choking episode to scare a child into not eating, not to mention the potential for serious consequences of food getting lodged in the airway.
With these types of recommendations, I have seen children who were struggling be able to eat the right amount of calories, be able to eat in a timely manner, gain weight, and eliminate choking almost immediately. Feeding therapy can then focus on improving chewing skills. I often tell parents that there is no quick fix for chewing. It takes time to to develop the skills needed for chewing including the motor planning, strength and coordination required.
- A child’s diet textures should be consistent with their oral motor abilities.
- Moving a child back to purees or mashed consistencies can help improve intake volume and subsequent weight gain, decrease food holding and expelling due to poor chewing, and decrease meal time length as well as caregiver frustration.
- Chewing practice can be provided with a smaller number of bites per meal, a portion of the meal, or even at snack times.
- High calorie liquids and purees can decrease the volume of food needed for weight gain and growth. (It is easiest to increase caloric density in liquids and purees- a future post)
Case example: I recently saw a 6 year old child who was partially tube fed and who was eating 3 meals per day orally of soft solids. Home therapy was working on chewing. He had low oral motor tone with open mouth resting posture. He had messy chewing with a lot of oral residue and oral spill and was making very slow progress toward oral eating.
After watching him eat, I recommended that he move back to purees and high calorie formula for meals and continue to work on chewing outside of meals. His mother called to report that by moving back to meals of homemade purees, he was able to come off of his feeding tube in 2 weeks and he continued to show weight gain! (note: tube was not removed immediately)
Now, therapy could focus on improving chewing skills at the child’s pace without the pressure of having to consume chewables for weight gain. (I will post more specifically on teaching chewing at a later date).