I discussed many of the factors that influence the process of learning to chew in part one. This post will focus more on strategies and therapeutic techniques to help children move from a sucking to a chewing pattern. To reiterate what I said in part one, this is a slow process. While therapists can never predict how long it will take a child to learn to chew, I can say it will usually take a minimum of 6 months if the child is starting from a sucking pattern and is ready to learn and practices regularly.
Determining Readiness: I typically start working on chewing after I have established acceptance of purees (preferably homemade purees) via spoon and the child opens and accepts well. While there are exceptions, if a child is mainly tube fed, we work on moving off the tube with purees and liquids and work on chewing later. Lastly, you do not need teeth to being the process. Sometimes a caregiver will say they think their child is not chewing because they don’t have teeth yet. Many children are munching and biting on dissolvable foods at 6 or 7 months.
Techniques and Strategies: Most of the therapeutic techniques we use are to work on the individual components of chewing:
- biting strength and stamina
- lateral tongue movement (as well as ROM, strength and control)
- jaw shifting
- rotational patterns in the body
Meal Consistency Recommendations – if a child is mainly using a sucking pattern, their meal consistency should be pureed or mashed foods and/or meltable solids. A child who cannot chew should not be given solids that need to be chewed. That seems like an obvious statement but many children come into therapy swallowing foods whole, holding them or spitting them out because they can’t chew them. The most concerning of these is trying to swallow foods that have not been chewed properly. This can lead to choking and airway obstruction and families should always be counseled about choking risk. Remember a child who has delayed oral- motor skills usually has a normal or typical mouth size. That means, the child can put larger bites into his mouth which can be a problem if the child does not know how to handle the food.
Secondly, eating is a learned behavior. Sucking on solids does not teach a child to chew. It teaches a child to suck on solids. What a child practices is what they learn. We want our patients to practice skills that will move improve their oral motor skills.
Lateral Placement of Puree – The first exercise I like to implement is lateral placement of puree. This involves placing a small amount of puree (a texture the child can handle) into the sides of the oral cavity which requires their tongue to move laterally to retrieve the bolus. This is usually the first prechewing technique I use because it starts to work on tongue lateralization but poses no choking risk. The technique I use is the following (it take 2 hands):
- use an infant size flat spoon ( I like the maroon spoon, EZ spoon, or even an infant spoon handle).
2. Use a small bite of smooth puree.
3.Caregiver feeds and should sit in front of the child giving a verbal cue to the child to “open”. Child should open his/her mouth fully for the spoon.
4. Caregiver uses one hand to lightly stabilize the head and the other to place spoon midline and then slide over to the side pulling the spoon out of the cheek. Puree is deposited in the cheek.
When we start this technique, we ask caregivers to feed the first 1-2 oz per meal with lateral placement and then the rest midline with larger bites if tolerated. It does slow the meal but consistent practice is crucial.
On a side note, no ever does it right the first time and it is harder than it seems. First, the child has to open for the whole spoon. I tell parents, it takes two hands, one to feed and the other to stabilize the child’s head or they tend to turn toward your spoon. And, you can’t go over to far into the cheek.
Lateral Tongue Exercises – Some children have difficulty moving or controlling their tongue. For chewing, a child needs to be able to “dissociate” their tongue and jaw. That means being able to move your tongue side to side without moving your jaw. When asked to do this, some children will protrude their tongue and then move their whole head side to side. Part of therapy can include more traditional oral motor exercises to work on better tongue control. These might include:
- lateral tongue movement in and outside the mouth
- licking food out of the corners of the mouth or from the back of a spoon placed in the corners of the mouth
- licking games
- pushing a food from one side of the mouth to the other with the tongue
- stretching of lingual frenulum and helping range of motion of the tongue
Biting – We also work on biting to build motor planning, strength and stamina. When we eat solid food such as an apple, we might bite 25-30 times for one piece! There are different ways to work on this:
- chewy tubes or chewing tools you can purchase that are placed laterally on the back teeth. We move kids from biting and holding to biting consecutively 30-40x or more. We start with biting on the dry tube but later in therapy may dip it in puree or flavors to add in the component of swallowing. Some therapists may use firm textured foods such as beef jerky or licorice to encourage side biting.* I recommend the Jaw Rehab Program if you would like to follow a protocol and use a more structured approach. I found this very helpful when I was a new therapist.
- Meltable or dissolvable solids – Meltables would include foods that dissolve or melt, you can find many options in the infant aisle at the grocery store. Examples include puffs, mum mums, ritz crackers, veggie sticks, etc. We start by placing 1 small piece on the back molars or gums with a verbal cue to bite with visual demonstration. If a child is resistant to the placement, we back down to crumbs placed laterally. Once the child can bite on the piece, we ask them bite several times in a row building in consecutive biting. We funnel a narrow piece of cracker with verbal cues to “bite, bite, bite”. We often alternate between the chewy tube biting and the meltable solid during practice sessions. While the child is biting, it helps for the feeder to add firm jaw support. You can often feel and see the difference in biting strength when you provide jaw support and when you remove it. Most children need jaw support to help with stabilization and strength.
- Chewy bags, biting on food in mesh, crumbs in a straw- many therapists use these to work on biting on food. I usually don’t unless a child really enjoys it. But I know many therapists do and find it helpful.
Lateral Transfer and Jaw Shifting – as children become more comfortable biting the solid foods, we work on moving the food from side to side with the tongue. Some children begin this process automatically and others will need help. Along with lateral transfer, you should begin to see some jaw shifting as well. I mention this because I have had patients with structural problems in the jaw that would not allow for any lateral jaw shift. For one child in particular, this meant that she could not move into mature chewing because all the work of moving food was being done solely by her tongue. Try chewing and not moving your jaw and you will see how difficult this is.
Gross Motor Exercises and Positioning – I often enlist the help of PT and OT for gross motor exercises that support chewing. These mainly include good upper body strength including head control, upper extremity strength, core strength, and trunk rotation. In development, we see postural alignment, core strength, and trunk rotation coming in before chewing. Activities to support body alignment, strength, and movement patterns can have a very positive effect on oral motor skills. Always pay attention to head and neck alignment in particular when working on chewing. If the child tends to have forward head posture and collapsed trunk from low tone, it can affect the tongue position and range making it harder to move to chewing.
Verbal and Visual Cueing – During practice, provide verbal cues to the child to “open”, “bite”, “crunch”, “bite like a tiger”. At the same time chew and bite with exaggerated open mouth movement. Chew with your mouth wide open so the child can see you biting and then show them how your tongue moves the food across your mouth to the other side. Many children will imitate you. We recommend parents do this at home as well.
Decrease Sucking – For some children it helps to move away from any kind of sucking the child might be doing. That might mean getting rid of a pacifier, moving from bottle, straw or sippy cup to an open cup. I often make these types of recommendations but would not want to compromise intake or cause weight loss in the process.
All of our kids are put on a home program with daily practice recommendations. It is crucial they practice a little every day to move forward. Initially, you will see the best chewing on dry meltable or crunchy type solids which tend to give the best sensory input. As you see children moving into the open mouth vertical chewing pattern with meltables, we begin incorporating them into mealtime and snacks. As they become easier, then we introduce easy soft solids into meals. This might include diced soft fruits and vegetables, shredded cheese, meat sticks, eggs, tofu, lunch meats, etc. We are watching for that open mouth lateral transfer and biting pattern. Slowly with practice, children will build stamina and coordination and will increase the amount of chewables they can handle in a meal. We also see new chewers moving between sucking and chewing for a long time as they learn to coordinate this new skill.