One of the more common reasons for a child to be referred to feeding therapy is poor chewing (also described as being stuck in a sucking or suckle pattern). This might present in the following ways:
- gagging, choking or vomiting on lumpy bumpy foods and/or on solids
- pocketing or holding food orally for a prolonged amount of time
- sucking on solids
- swallowing food whole
- expelling or spitting out solids
- refusal to eat solid foods with preference for liquids and purees
- poor intake due to difficulty manipulating food
Chewing is a complex motor pattern and a skill that in typical development takes two years or more for a child to move from sucking on liquids and purees to move toward rotary chewing of solids. It can takes children who are not chewing a LONG time to learn this skill. How long will it take for a child who can not chew to learn? That depends on several factors including readiness, the age of the child, their gross motor function, their GI tract and sensitivity, muscle tone and motor control, their willingness and desire for solids, and last but not least- practice. All of these factors can influence the transition from sucking to chewing. Let’s break these down.
Readiness – Most children come to therapy drinking liquids, eating purees, and struggling with their solids. The therapist will determine if the child is ready to work on chewing. There are certain factors that may influence this decision. If a child is failing to thrive or underweight, it may be more beneficial to work on increased acceptance of caloric intake with liquids and purees before working on chewing which tends to slow a child down a bit at meal time. Similarly, if a child is receiving all nutrition via tube feeding, we would opt to begin therapy with easy textures. Build acceptance of easy textures such as purees and liquids before moving to chewables with a child who is a non-oral feeder. Some children will naturally move to chewing and solids with the practice of oral feeding.
The age of the child – in typical development infants are starting to experiment with dissolvable solids around 7-8 months. This is where we first see munching and with practice over the first year of life, this matures into a vertical chewing pattern (lateral biting, jaw shifting, still some sucking). The infant’s mouth at 7-8 months is still small and because of their lack of fine motor coordination, they typically only get one piece of solid at a time allowing oral practice with munching, sucking, and moving it around. When a 2, 3, 4, or 5 year old is learning this same skill, they have to deal with a much larger oral cavity which demands better lingual movement and oral control to prevent choking. They also have better fine motor ability and can put more in their mouth at one time making it difficult to manipulate.Thus, the older the child is when starting to learn, the more challenging it can be. When I am working with an older child on the skill of chewing, I expect it to take longer.
Gross motor function – in typical development, many of the gross motor milestones come before oral skill development. Before a child begins spoon feeding purees and then accepting solids, most will have independent stability in sitting, trunk rotation, and will be beginning to crawl. This postural stability and rotational patterns in the body supports the stability needed in the head and neck and oral cavity. This supports the transition toward jaw stabilization and dissociation of tongue and jaw. For some of our clients, working on gross motor patterns and stability, as well as supported positioning, will help chewing progress.
GI tract and sensitivity – if a child is exhibiting oral hypersensitivity such as gagging, retching, or vomiting with solids it will be difficult to encourage intake and practice due to negative and unpleasant experiences. This may very well be the reason the child did not progress to solids during typical development. Some children are gagging/choking because they are swallowing food whole and when you take them back to mashed or pureed foods the choking stops. Overall intake may improve as well because the child can handle the food better. Some gagging is more sensory based/hypersensitivty and may be triggered with food on the lips, tongue or cheeks. There can be an added behavioral component as some children gag or vomit on site of food. There are different therapeutic practice recommendations on how best to deal with this type of problem. Some therapists begin a desensitzation approach in the oral cavity. The feeding team I work with prefers to treat this medically and nutritionally. We have seen improvement for our children with the use of different types of medicines for reflux, motility, pain, nausea, and constipation and by changing formula and/or slowing tube feeds. The goal is to improve overall GI comfort which hopefully results in elimination of gagging and vomiting allowing the child to comfortably move to solid textures.
Muscle tone and motor control – part of learning to chew, which involves stabilizing the jaw and moving the tongue is a motor pattern. If a child has hypotonia or low tone, it may make it harder for the child to stabilize the oral structures and have the strength for consecutive biting. The therapist may need to add jaw support or base of tongue stabilization (pressure under jaw to lingual muscle) to assist so the child can achieve a stronger biting pattern with less fatigue. Building strength with exercises takes time.
Willingness and desire for solids – it is easier to progress and practice when a child is excited about chewing and wants to participate in therapy. However, many children are nervous or anxious about having solids in their mouth. Therefore part of therapy may include encouraging the child and building a comfort with solids. This might include play activities such as feeding caregivers or a doll. This might also include crushing solids into crumbs and tasting, licking and practice moving solids on the tongue.
Practice – Last but not least, is the need for consistent daily practicing. Chewing is a skill that needs to be practiced. Children need to practice the components of chewing including lateral tongue movement, lateral movement and retrieval of the bolus, biting strength, and biting consecutively. I often help caregivers understand this and figure out the best way to fit in several short practice sessions during each day to help progression between therapy visits. This can be challenging as some of our kids have many doctor and therapy visits every week. Usually, our practice exercises are embedded into meal time to make it easier for caregivers.
Part 2: will discuss specific therapy exercises and strategies for working on chewing.