Working on Cup Drinking: The Benefits of Using an Open Cup

When it is time to start working on cup drinking, I typically start with an open cup. Every child’s situation is unique and must be considered individually when making the decision about which cup to use.

These are typical scenarios where an open cup may be beneficial:

1. The child refuses the cup and is solely dependent on bottle or breast feeding.

2. The child will drink water in a sippy cup but refuses formula in the cup.

3. The child will drink from a spouted sippy cup or straw but is stuck in a sucking pattern and is having difficulty progressing to chewing.

Choices of cups: There are many types of open cup designs. I typically use one of the following:

1. Sassy infatrainer- features a large lip and flow regulator for low, medium, and high flow (must buy these from a therapy website such as new visions or beyond play, etc)

   

2. medicine cup – 30 mL

3. cut out cup or nosey cup 

   Flexi Nosey Cup Combo – 1 of Each Size

4. 

5. 2 oz open cups or “shot” glasses

 

5. commercial cups with lips not spouts

                            

 

 

General Thoughts: There is no single cup that will work for all children but my favorite cup is the Sassy Infatrainer. It is designed as a transition cup from bottle or breast to cup. The wide lip allows for the child to stabilize the jaw and flow regulator prevents large volumes from entering the oral cavity at once. I have seen children who are resisting a cup or having oral spill with cup drinking have almost immediate improvement with the infatrainer. Of course, some children will refuse this cup as well but it is the cup I have the most success with this one. The Sassy Infatrainer is not available in stores. It is available online from various therapy resources.

Tips:

• Use thickened liquid in the cup to teach cup drinking: Some children will respond better to thickened liquid in the open cup. Thickened liquids will have a slower flow rate and give the child to respond to the liquid. I often use a smooth puree and then thin it with juice or water or yogurt into milk or formula. As the child improves you remove the thickener.

• Sometimes I take the child’s puree and put it in the med cup. That way you are only changing one things, the delivery not the food.

• Slightly thickened liquid will come through the Sassy infatrainer thicker liquid will not. But you can set it to to low flow for new cup drinkers.

• Tell caregivers to use formula and milk in the cup when training. Many caregivers keep the milk in the bottle and only put water or juice in the cup. This makes it harder for children to transition to drinking milk from the cup.

• Caregivers should start by offering the cup at meal time and snacks before taking away the bottle.

Using Behavioral Reinforcement for Cup Drinking

For children who refuse to accept a cup I begin teaching cup drinking using a behavioral approach. Initially, I establish the behavioral program teaching acceptance of a variety of purees. This is in the context of a structured feeding session and teaches the child to accept the dry spoon (empty spoon) or a bite followed by a reward. Once this relationship is established and the child responds with acceptance then the focus becomes volume and variety. This program is sent home with the child so caregivers can practice daily. As the child understands the rules of the program, ie., if they accept the bite, they get a reward, feeding improves. When the therapist determines the child is ready then cup drinking can be added into the program.

Positioning: It’s important that the child be positioned in a supported seat that promotes head and neck alignment. This might mean sitting in a highchair with straps, a car seat, a home wheel chair, or a feeder seat. It is important that the child be stable and ideally in a seat where they can’t get up if they do not want to participate. For many children, a chair with a high back can add stability and prevent the child from leaning over the back if they are refusing.

Cup Drinking

When using a behavioral program for cup drinking (or spoon feeding), the therapist does the feeding. Ideally, the feeder sits across from the child giving a verbal cue to “open” or “take a drink”. The feeder holds the cup and brings it to the child’s mouth providing a sip. Acceptance is followed by 20 seconds of play and verbal praise.

When using this approach, I usually start with a medicine cup to control the volume. I may start with tastes of thinned puree in the cup, formula, or water. I verbally cue the child with “open” and present the cup waiting for mouth opening. The cup is placed on the child’s lip and a taste or sip is delivered. This is followed by praise and play.

As the child progresses, the expectation for taking volume increased. I will put 5 mL or 10 mL in the cup and I tell the child when they take all the liquid in the cup, then they will get to play. It may take the child several drinks to complete the full amount. This teaches the child to slowly accept volume.

Many children will refuse the cup by closing their lips as the cup is presented. When presenting the cup, hold the cup in front of the child’s mouth and wait for opening. I might verbally cue the child “open big” or model but showing an open mouth. Place the cup on the child’s lower lip and deliver a small volume.

If the child has total refusal and resists even small sips from the cup, then I follow this protocol for acceptance of the cup, we work in these stages:

1. Acceptance of the dry cup: an empty medicine cup is brought to the child’s lips followed by reward. Usually, we will do 10-20 trials followed by reward. Caregivers follow protocol at home for specified number of trials daily. This is done until the child no longer resists.

2. Acceptance of cup rim dipped in puree or a flavor.

3. Acceptance of thickened liquids in open cup with a specific volume goal.

4. Acceptance of thin liquids in the cup with a specific volume goal.

As the child practices and gains cup drinking skills, then self feeding is encouraged.