How do OT’s work in feeding?
oral aversion
tube to oral transition
poor oral motor skills
poor hand to mouth coordination
Development of chewing: phasic bite, munching, tongue lateralization, vertical/diagonal/circular chewing
- phasic bite: birth - 3-5 mos
- munching: 6 mos
- tongue lateralization: emerges, 6 mos
- vertical chewing: 12 mos
- diagonal chewing: 18 mos
- rotary chewing: 18-36 mos
Why is tongue retraction important?
Retraction is needed:
- to place food from center of mouth onto teeth (retraction w/ lateralization)
- to drink properly from cup/straw
- for articulating every sound in the English language except “th”
Three common feeding issues:
- dyphagia: difficult swallowing (broad term)
- aspiration: food/drink/secretion enters lungs
- gastro esophageal reflux disease (GERD): stomach acid comes up instead of staying down and burns the lining of the esophagus
Signs of dysphagia:
MANY:
- frequent refusal to eat or drink
- irritable behavior during eating
- difficulty controlling saliva; drooling
- multiple swallows to get food down
- drinking often while eating (to help swallow)
- food left on tongue or pocketed in cheek
- frequent gagging, spitting, vomiting
- takes >30-40 minutes to eat
- weight loss of unclear origin; failure to gain well
- chin tuck during swallow
- congestion in nose (with babies - b/c milk goes up into nose during 3rd phase of swallow)
Signs of aspiration:
concrete signs: rise in temp. and/or Pulsox after eating
observational signs:
- coughing, hiccuping, burping during/after eating or drinking
- watery eyes during/after (“silent aspiration”)
- frequent pneumonia/respiratory infections
Signs of GERD:
- frequent refusal to eat/drink
- irritable behavior while eating
- finished eating before they are full
- arching back, turning head (trying to lengthen esophagus)
3 P’s of assessment:
- past medical hx (NOTE: if child is below 15th percentile for growth, get weight on first, then address feeding)
- pain (think GERD)
- poop (should be soft, daily)
what to do first:
- 1-week log to track child’s eating and pooping
- then interview: how is child fed? how much? how often? what do they eat? etc.
- DON’T JUDGE. Listen mostly. No more than 1-2 suggestions at first.
- Main goal: Build rapport.
good ORAL MOTOR assessment
good ORAL MOTOR tx program
Beckman Oral Motor assessment looks at:
- lip strength
- cheek strength
- sensory issues
- tongue ROM
- more…
Talk Tools Therapy by Sarah Rosenphal Johnson builds oral motor skills; great for kids who are cognitively able to follow directions
Intervention guidelines:
- base on assessed weaknesses
- help pt get comfortable and relaxed
- work your way to mouth, don’t dive right in!
sample interventions for lip closure, awareness, strength:
- closure: kiss “Z-Vibe,” blow through straw to move cotton ball, drink through straw
- awareness: vibrate lips w/ Z-vibe, place Z-vibe or baby spoon in ice water before putting on pt lips, fish faces in mirror w/ frosting on lips
- strength: “Talk Tools” bubble Heirarchy or button pull, blow whistles, plastic pinwheels, party blowers, noise makers (harder), etc
jaw strength interventions:
- Beckman resistive chew tube
- bite and hold with bite blockers or twizzlers
- put anything in polyester organza so they can chew it without choking
- (lots more “Lip Prints” items)
interventions for tongue awareness, lateralization, retraction, elevation
awareness: spicy foods (also helps control wt.), lick sour flavors (also faciliates pucker) fun dip or fire balls
lateralization: “hard munchable” like celery or carrot stick, mirror for silly faces, facilitate w/ Z-vibe, tongue “tag” w/ lollipop
retraction: Talk Tools straw program (develops a harder suck, so more retraction) or horn program
elevation: Z-vibe to facilitate, “tag,” Talk Tools Cheerio Hold Up
interventions for cheek strength:
- Z-vibe to inside or outside of cheek
- Beckman cheek stretches
- Vital Stim (need certification; but tell parents, so they can find someone else if they want)
sensory assessment:
- What will child let you touch? Hands, arms, cheeks, lips, mouth?
- what child eats now, always, sometimes, jags
- is there tactile sensitivity all over?
- hx of NG tube?
massage as intervention:
massage improves:
- wt gain
- circulation
- immune system (by moving lymhp)
- digestion/metabalosm
- bonding
3 thoughts re: tx planning
- ID your target food.
- Where will child allow the food to be? on table, placement, plate? Will child touch it with hand, nose, lip, tongue?
- Show progress thru proximity.
good intervention for sensory issues
Sequential Oral Sensory (SOS) is great for children w/ oral aversion and picky eaters. (by Dr. Kay Toomey)
Food chaining:
One at a time, change just one feature of an “accepted” food, i.e. if child eats pancakes:
- change shape by using cookie cutter
- change color w food dye
- change taste w vanilla or cinnamon, etc.
positioning checklist for feeding:
Normal guidelines for positioning, but also:
- Can the child move? Being strapped in tightly limits mobility needed for feeding and eating. (ALSO: if trying new and potentially chokeable food, DO NOT strap child in. You may need to pull them out quickly.)
- Can child interact w/ feeder and/or family and peers? Can child reach any assistive devices?
- Is feeder comfortable? Mind those body mechanics!
