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IMPROVING EATING BEHAVIORSIN CHILDREN WITH
FEEDING AVERSION
Presented by
Merry M. Meek, M.S., CCC-SLP
NDT Advanced Speech Instructor
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NORMAL ORAL-MOTOR
DEVELOPMENT
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NORMAL ORAL - MOTOR DEVELOPMENT
Traditionally oral-motor development has been viewed in terms of oral reflexes, the structural
aspects of the mouth and jaw, the motor activity of the tongue and mouth and the muscle tone ofthe cheeks and face. The sensory aspects of oral-motor function have not been stressed and
therefore their contribution is poorly understood.
I. Sensory Aspects
1. Vision:The importance of functional vision is rarely considered in the feeding process, but
should be, particularly if the child has any neuromotor involvement such as cerebral palsy.In some cases where children push back into extension or have exaggerated mouth opening
as the spoon approaches the mouth, functional visionmust be considered. The child may
not be able to maintain binocular fusion of the approaching spoon and therefore may see adouble image. In some instances bringing the spoon up from under the chin will diminish
this response and if so, is an indication of a possible functional vision problem. In addition,
the appearance of food has a great impact on how that food will be received. Children who
have not had much experience with food will often be unwilling to experience foods theyare notfamiliar with and often have aversive reactions to the color and size of food, as well
as the smell.2. Smell: Children who have had lengthy hospitalization, those fed primarily by tubes or
those with limited food variety acceptance, have a different developmental experience with
food. In many cases this includes the lack of experience of smell. Some children who have
had lengthy hospitalization become familiar with hospital smells and actually prefer them.This aspect of developmental experience with smell must be considered in treatment.
Therapy should include an active program of olfactory stimulation of various foods to
attempt to normalize this aspect of feeding.3. Taste:Taste is also an experience that may be lacking. Various tastes must be introduced
gradually and tolerance developed. Honoring the child's choices is extremely important. Awell organized feeding program will present a sequential and graded introduction of taste,
with consideration to texture.4. Tactile:Textures of foods have a great deal of importance. Some children do not like soft
foods that slide around the mouth. Other textures feel offensive and children withoutfeeding experience do not have the ability to move the bolus around or to deal with mixed
textures.
5. Auditory/Vibration: The auditory vibration experience of food adds an element ofexperience and this must be developed gradually. First with small bites and crunches of
small foods like pretzel sticks and softer foods with consistency like watermelon and apple.
II. Postural Aspects
1. Chin Tuck:Chin tuck allows good closure of the lips and the proper muscle activity of the
face and mouth for speech and feeding. Neck elongation is critical to the ability of the headto achieve capital flexion. As the neck elongates, the jaw moves forward and down into achin tuck. This provides the stability required for the oral musculature to developed graded
control.
2. Neck Elongation: The young infant does not have much of a neck. Over the first few monthsthe neck begins to elongate. This elongation allows a change in alignment of the structure of
the mouth and jaw. Neck elongation provides more mobility of the head and assists in
developing proximal stability of the shoulders.
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THE MUSCULATURE OF THE FACE
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THE MUSCULATURE OF THE TONGUE
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THE INFLUENCE OF RESPIRATION
ON FEEDING AND SPEECH
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ORAL-MOTOR ASSESSMENT
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ORAL MOTOR SPEECH EVALUATION
Merry M. Meek
PRIMARY AND SECONDARY MEDICAL DIAGNOSES:
1. General Postural Tone and Alignment
2. Changes in Facial Expression
3. 0ral-Facial Tone
4. Response to Finger Stimulation Outside Mouth/ Inside Mouth
5. Dental Development
6. Oral Reflexes (presence/absence)
Rooting reflex
Suck/Swallow reflex
Bite reflex
Gag reflex
7. Jaw Control
At rest
In activity
8. Tongue Control
At rest
In activity9. Lips andCheeks Control
At rest
In activity
10. Respiration Pattern (at rest and in activity)
Abdominal
Immature abdominal-thoracic
Mature abdominal-thoracic
Asynchronous
11. Feeding Behavior
Co-ordination of suck, swallow, respiration, rhythm
Lip closure during swallow
Normal bite
Munching-vertical chewing
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Vertical-rotary chewing
Jaw grading
12. Abnormal and compensatory patterns
Abnormal bite (tonic)
Jaw thrust
Jaw extension
Tongue thrust
Tongue protrusion
Drooling
13. Upper Gastrointestinal Results (UGI)
Oral, pharyngeal, esophageal phase of swallow
Presence of reflux
14. Reflux Evaluation
UGI Study
pH Monitor Study
Radioisotope Study
15. Respiration/Phonation
16. Articulation
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POTENTIAL RISK FOR ASPIRATION
1. Frequent coughing, choking, and/or gagging during meals.
2. Poor or no weight gain.3. Eating new food textures.
4. Rigid feeding behaviors.
5. Poor control of oral secretions.6. Wet/gurgly sounds before, during, and/or after eating and drinking activities.
7. Frequent irritability.
8. Poor sleep habits (e.g., difficulty going to sleep, frequent waking, restless sleeper).9. Frequent upper respiratory infections, and/or pneumonia.
10. Motor involvement which affects respiratory coordination, sensory-motor activity, muscle
tone, oral-motor function, and/or postural control against gravity.11. Functional problems of the oral and/or pharyngeal mechanisms which might result in
aspiration.
CRITERIA FOR REPEAT OPM STUDIES
Repeat oral-pharyngeal motility studies are indicated prior to implementing a significant changein an infant or child's oral-motor/feeding treatment plan, feeding equipment, or dietary texturesif:
1. there is a recurrence of symptoms previously thought to have been resolved,2. aspiration occurred without immediate, effective clearing of aspirated materials during the
previous study,
3. the initial study was terminated prior to completion,4. the initial study could not be analyzed, or
5. there is a significant medical change (e.g., surgery, medication change) which may affectoral-motor function.
Not to be duplicated without permission of author.
a:meek96-97\risk.asp
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TREATMENT GUIDELINES
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TREATMENT GUIDELINES
The management approach should include the following goals:
1. Identifying factors interfering with oral feeding.
2. Establishing adequate caloric intake.
3. Facilitating more normal postural tone and alignment and oral-facial tone.
4. Improving respiratory control.
5. Playing with foods in a variety of ways; using games, books, play foods, tea parties, "real Mr.Potato Heads".
6. Normalizing response to sensory stimulation.
A. Introducing a good oral hygiene program.
B. Normalizing the olfactory response to the "smell of food".
C. Encouraging hand-to-mouth and toy-to-mouth exploration if appropriate for his
chronological age.
D. Facilitating hand play with foods.
E. Introducing flavors on the child's fingers if he can reach his mouth and gradually thicken
the flavor (changes texture).
F. Using Nuk brush to facilitate vertical chewing helps to organize oral rhythm whilefacilitating for jaw stability, tongue lateralization, lip closure and controlled movements.
Graham cracker crumbs, Parmesan cheese, sugar sprinkles (dark- light brown sugar,colored sugar for cookies) can be effective because they melt.
G. Encouraging swallowing of small, thin 1/2 pieces noodles, cheese, cooked vegetableswith broth or drinking other liquid.
H. Developing oral sound play where indicated to facilitate coordinated oral movements.
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FOOD PARAMETERS
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Food Parameter
Visualize Feel Smell Taste
pictures/books develop names and interest
games - Lotto Lingo matching match to fake smells
spice bags fill strong
real foods or liquids
water all feel wet weak to strong liquids mix easy with sa
Capri Sun
clear pop
formula
variety of sugars rough sweet sugars melt with saliva
Parmesan cheese acidic cheese melts with saliva
pizza/spaghetti sauce
candy sticky sweet mix with saliva stays fil
noodles smooth bland
Cheetos, chips, thin pretzels rough salty strong
meat, vegetables rough strong
fruits hard strong
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Food Parameters
Visualize Feel Smell Taste
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SIZE IS EXTREMELY IMPORTANT
Finely grated or shredded Cheese, vegetables, or fruits
Granules White/brown sugar, decorative
sugars
Pinch Parmesan cheese, real bacon
bits
Tiny crumbs Pretzel thins, Cheetos, candy
strips, shoe string potato chips
Dip it in Any food they like - sweet/sour
sauce, pizza sauce, ranch
dressing
Small pieces no more than " Noodles, Cheerios pieces or
Rice Krispies
One drop others Clear liquids 1stunless like
already
Use children's dishes/tea party and baby dolls to feed if no peers are
included in session
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PHYSICAL HANDLING TECHNIQUES
FOR ORAL PREPARATION
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PREPARATION FOR THE TONGUE
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Management of Drooling
Assess: oral facial tone cervical alignment
Mouth closureTongue posture
Kinesthetic cues
Situations where drooling is occurring as part of
overflow
Treatment
I. Improve kinesthetic awareness. Improve oral
motor control. Improve swallowing
sequence.
II. Surgery to reroute salivary ducts
III. Scopolamine patches- antihistamine
IV. Other medications (see report formAACPDM)
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SPECIAL SYNDROMES
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Nager- Miller Syndrome Postaxial Acrofacial Dysostosis
1. Downward slanting palpebral fissures (eye lids)
2. Absence or underdeveloped cheek bones
3. Severely underdeveloped lower jaw
4. Malformed outer and middle ears
5. Cleft of hard or soft palate
6. Absence of lower eye lashes
7. Scalp hair extending on to cheek
8. Incompletely developed ulnar and radius bones
9. Underdeveloped or missing thumbs
10. Webbed finger and toes
11. Occasional absence of the radial limb
12. Shortened or bowed forearms
13. Limitation of elbow extension
14. Legs and toes may also be affected such as abnormal growth of
tibia and fibula bones
15. Stomach or kidney reflux
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DIAGNOSTIC CRITERIA OF RETT SYNDROME
ESSENTIAL CRITERIA
Normal prenatal and perinatal period
Normal birth head circumference
Apparently normal early development
Deceleration of head growth starting by 4 months CA
Loss of acquired hand skills
Loss of communication skills (words and interpersonal)
Stereotypic hand wringing or hand washing
SUPPORTIVE CRITERIA
Awake breathing dysfunction: apnea, hyperventilation, forced air or saliva
expulsion, air swallowing
Growth retardation
Bruxism
Seizures and electroencephalogram profile
Scoliosis
Vasomotor instability
Gait dyspraxia
Unprovoked laughing or screaming
Reduced or altered pain response
Eye pointing
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BIBLIOGRAPHY FOR ORAL MOTOR MANAGEMENT
Alexander, R., Boehme, R. & Cupps, B. (1993). Normal development of functional motor
skills. Tucson, AZ.: Therapy Skill Builders.
Bly, L. (1994). The components of normal movement in the first year of life andabnormal movement. Tucson, AZ. Therapy Skill Builders.
Glass, R. P. & Lucas, B. (1990). Making the transition from tube feeding to oral feeding.Nutrition Focus for Children with Special Health Care Needs, Vol. 5(6).
Langley, B. & Lombardino, L. (Spring, 1991). Neuro developmental strategies formanaging communication disorders in children with severe motor dysfunction, Pro-Ed.
Morris, S.E. (1989). Development of oral-motor skills in the neurologically impairmentchild receiving non-oral feedings. Dysphasia, 3, 134-154.
Morris, S.E. (1982). The normal acquisition of oral feeding skills: Implications for assessment
and treatment. Central Islip, NY: Therapeutic Media, Inc.
Morris, S.E. & Klein, M.D. (1988). Pre-feeding skills. Tucson, AZ: Therapy SkillBuilders, A Division of Communication Skill Builders.
Mueller, H. (1972). Facilitating feeding and pre-speech. In P. Pearson & C. Williams(Ed.), Physical therapy services in the developmental disabilities. Springfield, IL: C.C. Thomas.
Nelson, C., Meek, M., Moore, J.C. (1994). Head-neck treatment issues as a base for oral-motor function. Clinician's View. Albuquerque, NM.
Satter, E. (1987). How to get your kid to eat, but not too much. Palo Alto, CA." BullPublishing Co.
Schemer, A. L. & Tscharnuter, I. (1990). Early diagnosis and therapy in cerebral palsy.
New York: Mercel Dekker, Inc.
Wolf, L. F. & Glass, R.P. (1992). Feeding and swallowing disorders in infancy:
Assessment and management. Tucson, AZ. Therapy Skill Builders.
Young, E. H. (1964). Motor-kinesthetic speech training. Stanford University Press.