The Center for Pediatric Feeding & Swallowing
St. Joseph’s Children’s Hospital, Paterson, NJ
Failure to advance texture is a very common feeding problem for many children. Successful advancement of texture is dependent on the ability to move the tongue freely and fluidly throughout the oral cavity while the jaw remains stable. For many children with feeding problems minimal tongue movements are used while eating or drinking. They may depend on a suckle transport, whereby the tongue moves with the jaw in and out of the mouth, using their lips and jaw more than tongue movement. With spoon feedings, the tongue is often held posteriorly within the oral cavity. The spoon enters the mouth, makes minimal to no contact with the tongue, and the food is deposited in the anterior portion of the mouth. The child can then successfully, but not appropriately, move the purees posteriorly using the suckle transport pattern. Gagging can often occur because the tongue is not effectively controlling the movement of the food and is maintained because the tongue freezes rather than moves.
Usually when the child maintains the retracted tongue posture they compensate for not moving their tongue by using their lips and teeth to clear any food from outside the mouth instead of using their tongue to lick it away.
The first thing necessary when working with a child with tongue retraction is to find out why the tongue is retracted. Observe how they can move the tongue without food in the mouth. If the tongue is not retracted at rest and moves freely within and outside of the mouth then there is less probability of a neurologic problem .
Tongue retraction often signals a defensive posture: it is meant to minimize entry into the mouth and as a result tongue movement is restricted. The feeding history chronologically integrated with the medical history will alert you to medical problems that could be contributing to the child’s feeding problem. Any medical condition that impairs the function of the respiratory or GI tract can reduce the child’s interest in eating as well as their tolerance for increased or new oral stimulation. In our experience discomfort from GER, fullness from constipation, delayed emptying, or irritation related to food allergy or intolerance are common problems resulting in tongue retraction. If a medical issue is identified, the child will respond much better to oral motor intervention if the issue can be resolved or remediated first.
Poor postural alignment can also contribute to tongue retraction. It is important to understand that postural alignment of the trunk supports the shoulders, which provide the base of support for the muscles of swallowing. Slumping or slouching misaligns the position of the shoulders, head and neck, which encourages retracted positioning of the tongue. Thus, correct alignment starting with the pelvis, through the trunk, shoulder girdle, and then head and neck are essential to minimizing tongue retraction.
To correctly swallow pureed food from a spoon, or a sip of liquid from a cup, the child needs to use a single anterior to posterior tongue movement with the jaw stabilized. This can be stimulated by putting a press onto the mid-tongue with the spoon and then pull the spoon out slowly while providing chin support. Often the child with tongue retraction has minimal mouth openings for the spoon; a few do not open wide enough for the tip of the spoon to go beyond the child’s teeth. When mouth opening is minimal it is very difficult to get the entire bowl of the spoon cannot be placed on the child’s tongue. We recommend presenting very small volumes on a small, shallow bowled spoon that easily fits into the child’s mouth. We recommend for the parents to shape a wider opening by placing the spoon to the child’s upper lip and waiting for the child to open slightly wider than they typically open. Once the child is readily opening slightly wider, the parent can wait for slightly bigger openings. The parent should continue to wait for gradually bigger openings until the child is opening wide enough for the entire spoon to be placed on the child’s tongue. Providing access to a preferred object contingent upon wider openings may help but only if the parent is able to wait for the child to open bigger upon spoon presentation.
Providing chin support is crucial during this technique to provide stability to the jaw to allow the tongue to move independent of the jaw. This technique is typically provided during feedings, but can also be initiated with a dry spoon.
In addition to this, there are other “tongue exercises” that can be practiced both during meals and outside of meals. Leaving some food on the lips and encouraging the child to lick lips facilitates forward and lateral movement of the tongue. This can also be done without food and using a verbal/visual prompt to lick lips. Using stimuli such as a lollipop, twizzler, carrot, or non-food item, such as a chewy tube, you can roll these objects over the tongue, both from front to back, back to front and side to side to “loosen up” the tongue. Other exercises include holding food/object to side of lips and inside cheeks to stimulate tongue movement toward them, or wiping a sticky taste on lips or into cheeks or on teeth to stimulate movement.
With children who can understand verbal commands, pretending the tongue is a shovel and can dig in between the lips and teeth and cheeks and teeth also stimulates good tongue movement.
Often times, it is best to start any of these exercises without food and as the child becomes more comfortable, begin to use food to stimulate the tongue movement. Once the tongue appears to lay flat in the oral cavity and accepting the spoon on it easily, lateral placement of the spoon during feedings of purees can be initiated to further stimulate lateral tongue movement in preparation for advancing to solid foods.
The team approach works to answer the questions everyone has when evaluating a child with feeding problems. Multidisciplinary collaboration is necessary to answer the why and solve the how. The parents are an integral part of the team, implementing the treatment strategies recommended and providing feedback to enable the team to continue to reassess the child’s progress.