Oral Motor Feeding Lecture Flashcards
Swallowing: Oral Phase
- Reflexive in young infants and voluntary in older children.
- Oral manipulation results in a bolus being formed
- Mouth prepares food or liquid for swallowing
- Jaw, lips, cheeks, tongue, hard and soft palate work together
* Draw milk from nipple
* Develop a bolus - Tongue moves bolus toward back of the mouth where swallow reflex is triggered
- This phase terminates with the trigger of the swallow.
Swallowing: Pharyngeal Phase
-Back of tongue lifts to prevent bolus from returning to the mouth
-Soft palate lifts so that bolus does not enter nose
-Muscles in throat move bolus toward the esophagus
-Epiglottis covers the trachea (wind pipe)
-Vocal cords close to give added protection to the trachea
-The swallow is initially voluntary during the Pharyngeal Phase.
-Swallow in infants is ½ sec
-The glottis closes to protect the airway with movements
-Further protection is offered when the false and true vocal folds adduct
-Structural deficits or poor coordination due to neurological
deficits can impair this protective process, resulting in aspiration
○ Aspiration can occur before, during, and after a swallow.
Swallowing: Esophageal Phase
- Reflexive
- Bolus moves safely pass the airway
- Duration 6 to 10 seconds.
- Muscles at the top of the esophagus open to let milk/food pass and then close
- Peristaltic wave action of esophagus propels bolus to stomach
- Valve at entrance of the stomach that prevents reflux
○ It ends with allowing food to enter the stomach
Newborn Feeding
● Rooting reflex allows latching on to nipple
● Has gag and cough to protect the airway
● Can usually feed in 20-25 minutes
● Rhythmic, sustained, and efficient, strength
diminishes with satiation
● Suck-swallow-breathe at one month
Sucking
● Non-nutritive Sucking – rapid and rhythmic, two sucks per second
● Nutritive Sucking – consists of a burst and pause, with breathes during the pause. Rate and rhythm of
sucking varies with age of the infant.
Two characteristics of sucking that are most important for feeding are:
● Rhythm of sucking
● Type of suction on nipple
0-4 Months sucking
● This is the first sucking pattern
● Characterized by forward and backward movement of the tongue (as in a licking motion), combined with jaw opening and closing.
● Lips are together, but loosely approximated
● Suck-swallow-breathe pattern of 3-4 month old is 20 sucks before a pause
● Swallowing occurs after 4-5 sucks without pausing
6 months sucking
● Strong up and down movement of the tongue (raising and lowering)
● As jaw stability increases better control of tongue movement emerges
● The tongue moves more independently of the jaw
● Lip seal is strong
9 months sucking
● Better cup drinking
● Jaw is not stable on rim so there is liquid loss and mess which is normal
● Jaw moves up and down in fairly wide excursions and it is jaw movement that is primarily responsible for liquid intake
● Suck –swallow-breathe on a cup is one to three sucks from the cup, then swallow and breathe
12 month sucking
● Better cup drinking
● Tongue elevates to bring liquid into mouth
● begins tongue tip elevation in swallow
● suck –swallow-breathe on a cup– swallow follows suck without pausing and there are three continuous sucks before pausing
Cup Drinking:
● May bite on cup to achieve jaw stability (this is normal)
● Upper lip closes on edge of cup to
provide seal for drinking
● Child can usually take liquids from a
sippy cup at this age by self
● On a bottle or breast, long sucking
sequences are present
15-18 Months sucking
● Period of development of jaw stabilization
● Excellent coordination of suck-swallow- breathe
● Swallow follow sucking without pauses
18-24 Months sucking
18 months
● Up and down movement of tongue with tongue tip elevation
● Internal jaw stability, jaw appears to be relatively still
● Child can control intake of liquid from cup with lips rather than teeth
● Tongue is then more active during swallow 24 months – mature cup drinking
● Easy swallow with lip closure
● No liquid loss
● Child can drink by self from a cup without a lid by self without spilling
● Can drink from a straw – requires a good seal and strong suction
Development of Chewing
● Bite reflex is present birth to 3-5 months and this is normal. Rhythmical bite and release
with jaw opening and closing is seen when gums are stimulated.
5 months
● Beginning of munching pattern,
● There is spreading and flattening of the tongue (called extension and retraction) combined with up and down motion of the jaw.
● Tongue may elevate and touch the hard palate, but makes no lateral movement to move the food sideways. Food is mashed against the hard palate.
● This pattern seems to be a combination of sucking and a bite reflex.
6 months
● Gradual change to chewing pattern begins with gross lateral tongue movements when food is placed on the side between the gums.
● Tongue transfers food placed in the center to the side, then moves food from one side to the other, across the midline.
● Jaw movements in chewing are first vertical then later, lateral, then rotary.
7-8 months
● Variable up and down movement of the jaw; some diagonal movement when the texture requires it.
9 months
● Child manages pureed and soft solids
● Munching with diagonal jaw movement
● Child is able to transfer food presented at the center to the side using lateral tongue movement.
● Lips make contact as jaw moves up and down.
● Finger foods usually presented at this time.
12 months
● Rotary chewing is possible as child gains jaw stability and mobility
● Well graded bites on cookies
● Tongue is active, moving food from center of the mouth to the side, licking food from the lips. Tongue
tip elevation demonstrated.
18 months
● Well-coordinated rotary chewing for soft meats and various table foods
● Can control bite of hard cookie or pretzel.
24 months
● Child can chew most meats and raw vegetables
● Grade and sustain bite
● Circular jaw movements
● Tongue moves from side to side
● Tongue clears lips and gums
● Lip closure during chewing
Early Motor Development: Feeding
0-3 months
* Bottle/breast fed
* Using reflexes to find, latch onto a nipple, & suck/swallow
* Coordinating a continuous suckle-swallow-breath pattern (rhythm!)
* Strong protective gag reflex
4-6 months
* First foods introduced (usually smooth purees, cereals)
* Generalized mouthing (hands, feet, objects)
* Can use tongue to move food back to swallow
* From suckling to sucking
* Emerging vertical jaw movements
7-9
* Lumpy mashed foods
* Discriminative mouthing
* Uses lips to strip food from spoon
* Can move food from middle to either side
* Drinks from straws, cups with assistance
* Front teeth erupt, able to take crunchy meltable solids
* From munching to more controlled, sustained bites
10-12
* From vertical to diagonal chewing
* Can move food from one side to the other without stopping in middle
* From self-feeding with fingers to utensils
* More independence with cup drinking
* Can eat mixed consistencies
12-18
* Can handle coarsely chopped table foods including meats, raw veggies
* From diagonal to rotary chewing
* May show preferences and language skills support their ability to choose/refuse
* Uses cheeks and tongue together to keep control food during chewing
* Controls saliva/No drooling except when teething
What can infants eat?
● 1-4 months: liquids
● 5 months: liquids and pureed foods
● 8-9 months: soft, mashed foods
● 12 months: easily chewed foods including soft meats
● 18 months: coarsely chopped table foods, some raw fruits, cooked meats.
● 24 months: most table foods use caution with skins, tough meats, or small round foods that cause choking.
Feeding Problem?: Warning Signs
● Limited advancement in food texture tolerance
● Dependent on single form of calories
● High rates of resistive behavior during mealtime
● Consecutive months of weightless
● Crossing major weight percentiles
● Poor/slowed growth
Atypical Oral Motor Development
● Poor oral motor control
○ i.e. “Tongue tie”, Cleft palate, Cleft lip, Torticollis
● Instability/Asymmetry
○ Jaw sliding
○ Open mouth
○ Unable to dissociate
Reasons behind Feeding Challenges
in Children
● Premature infants or any infant with physiological stress impacting feeding
● Oral anomalies (e.g. cleft palate)
● Underlying problems of motor control (CP)
● Cognitive delays and difficulties learning to eat and using utensils
● Parent presentation or stress surrounding mealtime
● Sensory Issues
Many children demonstrate combinations of the above.
Indications for Referral for
Swallowing Evaluation
● Increased congestions or wet quality of voice during or after eating
● Frequent respiratory illness
● Significant neurological diagnosis or neuromotor involvement
● Coughing or choking on liquids or other consistencies
● Oral motor dysfunction
● Prolonged mealtimes
● Reliance on GI tube but is willing to eat some things by mouth
Dysphagia and Respiratory
Disorder
Dysphagia = “An impairment in the oral, pharyngeal, or esophageal phases of the swallow.”
Consequences:
Respiratory disorders
-Aspiration
-Asthma
-Apnea
-Chronic Lung Disease
Assessment/Testing
● MBSS (Modified Barium Swallow Study): Useful for evaluating aspiration or risk of aspiration and in assessing treatment for infants and children with feeding disorders. Patient exposed to 5 minutes of radiation while different foo textures are tried out
● FEES (Fiberoptic endoscopic evaluation of swallowing): uses a flexible endoscope with a light and camera inserted in nostril. A camera records the pharyngeal swallow
from inside as child swallows.
● An upper GI series is used for anatomic differences
● GI malrotation, fistulas which may cause vomiting
● Endoscopy: Used to evaluate the esophagus, stomach, and duodenum. Tissue biopsies can be taken to assess for eosinophils which are present in abundance secondary to severe food allergies.
Task Analysis of chewing
● Repetitive lateral bite
● Stability through the lateral borders of the tongue
● Tongue retraction
● Tongue tip pointing
● Contraction of the lateral borders of the tongue for lateralization
● Cheek contraction
● Lip closure
● Adequate jaw strength
● Ability to collect a bolus for a swallow
● Transfer of a bolus across the midline
● Bolus to midline
● Tongue retraction to swallow
Task Analysis: Cup
Drinking
● Upper lip mobility
● Lip closure
● Cheek contraction
● Jaw position
● Jaw-lip-tongue dissociation
● Stability through lateral borders of tongue
● Tongue retraction
● Tongue tip dissociation
● Coordination for sequential suck-swallow
Task Analysis:
Straw Feeding
● Lip Rounding
● High jaw position
● Jaw-lip-tongue dissociation
● Cheek contraction
● Stability through lateral border of tongue
● Tongue retraction
● Tongue tip dissociation
● Intraoral suctioning
● Motor planning for sequential suck-swallow
Interventions to improve self-
feeding: For children with tactile hypersensitivity
○ Start with activities reduce hypersensitivity outside of meal times
○ During meal times use variety of spoons or adaptive tool a child can tolerate
● Frequent gagging in a child may be caused:
● By abnormal hypersensitivity of the gag or swallowing difficulties.
● If the child is unable to move food efficiently into the pharynx for swallowing, particles which
remain may trigger a normal gag.
