Many children with feeding difficulty have aversive feeding behaviors or learned refusal patterns around the act of eating or feeding. I often tell my students that if a child doesn’t want to eat, you can’t make them. By the time children come to our feeding team, many caregivers have tried multiple ways to get there kids to eat. Usually they have tried force feeding and/or letting the child get very hungry. Neither of these alone will fix a feeding problem which are typically multifactorial in nature.
Children refuse foods in many different ways. Here is a list of some of the most common aversive feeding behaviors:
- Poor mouth opening for the spoon.
- Refusing foods by turning away, blocking the spoon, covering their mouth.
- Irritability and tantrums during feeding attempts, saying “no”.
- Expelling foods.
- Drinking instead of eating.
- Using delay tactics to stall the next bite.
- Refusal to sit in a highchair or at the table.
- Accepting only specific foods by type, texture, or brand.
For this post, I am going to concentrate on the first one, poor mouth opening for the spoon. This is very common with our food refusers. These are the kids that look like they are accepting the bite and then more than half of the puree comes off the spoon on the way into the mouth. I have also noticed that when caregivers are feeding a child who is hard to feed, they develop maladaptive feeding techniques such as dumping the food into the mouth, scraping the spoon off the upper gums, or loading the spoon (because they may only get a few bites) and shoving what they can into the oral cavity.
Let me tell you about a little guy I used to work with. I can remember him sitting in the highchair one day and we were working on acceptance of the dry spoon. Sometimes we call this “spoon game”. The idea is that we want to start where the child can be successful and for many kids that is without food. We are going to work on shaping behavior toward oral feeding and one of the starting places is having a child accept the spoon.
And I mean acceptance of the whole spoon– the goal is
- mouth opens with tongue down on the floor of the mouth
- therapist places spoon on child’s tongue with slight pressure
- child closes lips
- spoon comes out
During this particular therapy session, the child who I will call Charlie was sitting in the highchair. He was a little under the age of 2. I presented the spoon with a verbal cue to “open” and Charlie would respond by opening his mouth a crack, enough to let the tip of the spoon through his lips but not into his mouth. I tried multiple times with toy reward, verbal cueing, and visually showing him but Charlie continued opening his mouth only a crack. After a short period, we let him get down from the highchair, while I talked with his mother. Wouldn’t you know Charlie walked right up to me, tapped my leg, looked at me and opened his mouth as wide as he could. Then walked away pleased with himself.
I am happy to report that after feeding therapy, Charlie is now a good eater and is eating table foods well and has never looked back. Those days of poor mouth opening are long behind him.
So why do I persist on getting full acceptance of the spoon?
For several reasons:
- To successfully eat from a spoon you must be able to accept the spoon in your mouth. I have dubbed this teaching “spoon technique”. For some of our kids the decreased mouth opening is a behavioral response not a physical one.
- If we can establish acceptance of the spoon, it opens up the ability to work on many things: decreasing a humped or retracted tongue, lateral placement of the puree as a pre-chewing exercise, introducing new flavors and textures, and lip closure.
So how do we get mouth opening?
- Child should be positioned in a highchair or supported seat.
- Start with a dry or empty maroon or infant size flat spoon.
- Caregiver or therapist feeds the child, present the spoon and say “open”
- If the child does not open wide enough, I might say “big open’ and I model an open mouth posture, sometimes I add a sound cue “ah”.
- If the child still is not opening, then I use the spoon on the upper lip and tap upwards on the lip while I provide jaw stability with my other hand. Most kids will open with this technique.
- Then I place the spoon on their tongue with slight pressure before coming out of the mouth with the child’s lip closure.
- I also consistently use reinforcement (toys, verbal praise,etc) when the child opens so they are motivated to do it again.
Usually, I will not move onto to purees until I get good consistent opening for the dry spoon. The exception is some kids open better if there is something on the spoon so I might use a dip spoon in water, juice, or a thin puree. If using food, I stay at a dip level until we have consistent spoon technique of good opening.
Home practice: I teach parents to use this technique and I ask them to practice a certain number of times each day at home. Then at the next session, I ask the parents to feed and to show me how it is going. If it is going well, we move up to dips or small bite volumes of smooth puree.
My son was a re-flux baby but I thought he has outgrown it as he grew older (17 months now). I am told by the medical practitioner (not my pediatrician) that my son is still suffering from re-flux just that he has learnt to hide the symptoms. I understand this therapy takes time but wouldn’t it be nice if there was a provision to have the therapist come home and practice their techniques, instead of taking my son to the therapy center.
At this stage we have figured out that, my son does not need any special treatment that could only be done at the Therapy Center. So if there are any services where the Therapist can come for home visits that would ideal. I also feel that this kind of Therapy if done regularly can help the child quickly as opposed to doing the therapy once a week.
I live in Richmond, VA and to have anyone come home and come daily would really help me speed up my son’s behavior towards food. Any pointers shall be very helpful.
Shreya,
I am sorry that I missed your comment. How is your son doing? You mention he has reflux but not his feeding issues? I don’t know of any locally based feeding therapy that comes to your house daily. As a feeding therapist, I feel one of my jobs is to teach you the parent how to carry out the techniques used in therapy. That way you will feel confident about feeding your child and the child will get to practice every day.
Depending, on your child’s feeding issues, there are intensive or “day treatment” programs that you can take your child too that will work with your child during the day, every day, for a number of weeks. There is one in Richmond but the program would have to determine if your child is a candidate for their program.
feel free to email me back , Krisi
Hi, question I have is if you are a parent doing as you have stated above would you stop giving solids altogether and focus more on getting the child to accept the spoon? Will that not inevitably mean that they could forget the swallow reflex in the period that it takes for the child to accept the spoon into their mouth, and how long does it (as an average) take for a child to accept the spoon and then reaccept the spoon with some purree on it?
We are stuck see in this cycle of services unable/unwilling to help as they aren’t sure it’s safe without having enough solids/liquids going in to do a vp. We just have the advice to positively reinforce, no real techniques or explaination. I learnt alot on this article.
I tried this and it worked fine at first but it’s not working now.
What if the child opens the mouth for the dry spoon , but refuses spoon dipped in purée? How doesnone convince a child that is 11 months old to open his mouth?
Hi that was a nice technique, but seriously it’s not working with my toddler!!
The moment I keep the spoon near his mouth and start tapping he would have already finished opening and closing his mouth.
If I try to give support to his jaw with my hand he would withdraw and move back.
Pleas help me its been a great task feeding him.
Hi..I don’t know what to say about feeding habit of my baby….he is 22 month old.but till now he don’t know how to eat…he don’t close his lips over spoon.he can’t even drink from cup as he keeps his lip open till d time cup touches his mouth…he will only close his lips only when I remove the spoon or cup from his mouth..
He has feeding problem from very beginning…as suggested by doc we had to start solid at 5 month as he was quite underweight…he was never interested in food.The moment he saw food,he would immediately turn his head away.so we had to force feed him that time by pouring down food in his mouth…We thought this habit will change once he start showing interest in food..but this has never happened…Till now he is not interested in any type of solid food.And he is also delayed in speech…
I need some serious advice how to improve his feeding habit..i can’t go to any speech therapist as no one is available here…
Hi Niha
After I read your post, saying ditto would also be an understatement. My son is 20 months old and is exactly (word to word) same.
I am at my wits end and literally break down every single night not being able to understand what to do… I literally have tried every trick in the book..
Please please help me out if you got any success in your child’s eating pattern, accepting the spoon, opening the mouth, eating solids, chewing, and not being so damn averse to all sorts of food.
I really need some help..
I would really be very grateful..
Thanks so much in advance.
Hello what is my 2 year old knows how to open his mouth but doesn’t want to because he refuses to eat.
Good post will try to implement it
My 19 month old used to eat thrice a day and now since a month suddenly stopped opening his mouth. He fusses at meal times. The only reason he sits for a few bites is because his favourite jingle is on iPad. Today in the morning he just ate a few rice crispies before going to school and half his milk. What to do? Shall I change his food?
7 month old on tube feeding and top up breast feeding. Told to start introducing puréed food. Get it in his mouth, but he just spits it out. He can swallow when breast feeding. He is not gaining enough weight even with prescription formula additive to my breast milk with tube. Need to get him eating and off tube feeding. Help! And yes, we see a paediatrician regularly. Also have nursing team visit regularly. No one can provide answers as to why all this is happening.
Feeding problems can be challenging and difficult to treat. I would suggest an evaluation with a speech pathologist or occupational therapist that specializes in feeding or a feeding team.
Hi Krisi,
This is a very good article and I intend to practice this at home for my son (1yr). He shows all the 8 signs mentioned in your post above. Could you please help us in addressing the other 7 behaviors too? My wife is getting into a mode of depression because of my son’s non-eating behaviors and I can only do so much to improve the conditions. It would be really helpful if you can guide us here!
Thanks a lot in advance,
Sunil
I have a 13 months old who’s already on feeding therapy but I feel it’s not working. He still won’t open his mouth to be fed. He sees a spoon then screams and turns his head away. He also has sensitive issues when he touches purees or something wet it makes him gag. If I feed him anything with a spoon he will puck. Even breast milk. I am lost and VERY frustrated.
Hi. I am from Bangalore India with my 10 months old daughter with all the aversal behaviours. Can I have a skype appointment or gtalk appointment with you. Ankita
Hello , my son is 7 month old and is doing the same behavior of not opening his mouth . He opens his mouth for any other object besides the spoon . We have tried the dry spoon and he plays with the spoon and try to put it in the mouth is fine . But every time I try to add purée and feed with the spoon he keeps his mouth shut .i have tried to add the purée with spoon in the mouth ( closed lips ) so he sips the purée but this is very rare too …. it just depends on the mood . What excercise can I do to help him open his mouth to eat ? Please help .i use the baby sit and he sits up ( weakly )… we are still working on his back to be stronge … but he sits supported fine
My son is almost 16 & is refusing to eat with a spoon & open his mouth. He has selective mutism & anxiety so he goes threw many changes. But now he only wants to eat ice cream, yogurt, jello, pudding, but does it with his hands & is dropping weight . I took him to the hospital but they said they couldn’t do anything that it was behavioral. I don’t no what to do