Feeding Intervention

These are for your reference and are review of previously learned material. We will NOT
go over this in class.
Typical Development: Caregiver and Child Interactions
0-2 Months
Childs behavior/cues Caregivers behavior
Normal Oral Motor/Swallowing Stimulates Rooting
Skills Feeds on demand
Provides Hunger Cues Promotes a stable posture
Remains calm Eye contact
Normal appetite Monitor stimulation

3-6 Months
Childs behavior Caregivers behavior
Sleep/wake patterns become more Transition from feeding on demand
regular to developing a schedule
Increase in social cues Reading cues becomes a priority

6-36 Months
Childs behavior
Exerting control
Developing self esteem and
self concept
Emphasis is on role as a
family member
Begins self-feeding
Caregivers behavior
Transition from childs schedule to
family mealtime schedule
Family mealtime
Encourage independence
Lets the child set the pace
Encourages variety/ respects a
childs choices

Infancy - Structural Considerations:

Infants jaw is smaller
Sucking pads (fat pads) in tongue and cheeks help to secure the nipple.
Epiglottis and soft palate close to allow for a reclined position.
Prevents aspiration
 Normal Swallowing and Oral Motor Development

Oral stage
Oral prep (voluntary)
Lip, jaw, cheeks, tongue prepare food for swallowing
Oral phase (voluntary)
Posterior propulsion of food
Ends at trigger of swallow

Pharyngeal Phase
Voluntary and involuntary
Airway protected
Elevation of soft palate
Opening of UES
Larynx closed
Vocal folds adduct
Tongue propulsion
Pharynx clearance

Esophageal Phase
Non-voluntary
Starts at Upper Esophageal Sphincter
Peristalsis
Ends at Gastro-esophageal sphincter

Normal Feeding Skills Development

Early Infancy
Premature infants- generally fed non-oral means at least through 33 weeks
First suck is a suckle-horizontal pattern
Full term infant- sucking on a bottle
Newborn- 1 suck/1 swallow, rooting reflex
3-4 months-some liquid loss, 20 suckles before pause, swallowing after 4-5
sucks
6 months- vertical suck, liquid loss not common

4-6 Months
Suckle/Suck- full suck on bottle at 6 months
Spoon Feeding
Suckle pattern- lots of food loss

6-9 Months
Loses suckle on spoon, some lip closure over spoon emerges
Sucks on rim of cup- liquid loss
Gums food with a vertical pattern
At 9 months can manage first finger-foods that dissolve or mash in the mouth
9-12 Months

Vertical chew with some diagonal emerging

Can manage diced soft fruit, vegetables, bread products
Sustained bite on cracker
More efficient with cup, less liquid loss

12-18 months
Diagonal chewing develops
Transfers food from midline to sides
Expands table foods

18-24 months
Emerging rotary chew
Inconsistent close mouth chew
Emerging rotary chew
Inconsistent close mouth chew

24 months+
More frequent closed mouth chew
Circular rotary chewing
Transfers food from both sides of the mouth across the midline

Self Feeding
Developmental Continuum in self feeding

Age Performance Sensorimotor skills

5-7 months Takes cereal or pureed food from Head stability
spoon
Tolerates textures
Puts toys in mouth
Lip and jaw closure
6-8 months Attempts to hold bottle Midline skills
Strength and appropriate tone
6-9 months Holds and eats a cracker Good sitting skills
Sucks on but can sometimes bite Lateral pinch or radial grasp
Plays with spoon by banging it Supination
Jaw closure

9-13 months Finger feeds self soft table foods Various grasps
 Objects if fed by an adult
12-14 months Dips spoon and rings to the mouth
Spills contents and often inverted
15-18 months Scoops food with spoon and brings to
mouth
24-30 months Starts to use a fork
Is proficient with spoon
Isolate the radial fingers for smaller objects
Voluntary release
Uses pronation instead of radial deviation
Body awareness
Smooth fluid movements
Shoulder and wrist stability
Precise and smooth movements
Bilateral integration
Tolerates a variety of textures.
Supination
Strength to stab

Feeding dysfunction
Under-Nutrition (FTT)
- Height/weight under 5th percentile
- "Growth Faltering" over two parameters
o Over 3 months for infants
o 6+ months for children over 12 months

Factors Related to Under-Nutrition

- Poor caloric intake
- Increased calorie need
- Metabolic problems
- Behavioral problems
- Dental problems
- Cardiac disease
- Airway obstruction/respiratory problems
- Genetic disorders
- Food withheld
- Neurological conditions
- GI problems

GI Problems
Reflux:
- Gastroesphageal Reflux Disease (GERD) Long term return of stomach contents to
esophagus.

Symptoms of GERD
Burping (wet burps) Emesis
Heartburn Nausea
Frequent swallow Food refusal
Food refusal-esp. higher textures Under-nutrition
Chronic couch Hoarseness
Clearing one's throat Apnea
Asthma symptoms Stridor
Ear infections Sinusitis
Halitosis

History of Tube Feeding

- Orogastric, Nasogastric, Gastrostomy
- Poor appetite, inexperience of typical mealtime experiences

Respiratory Disorders
- Chronic lung disease
- Laryngomalacia
- Vocal fold paralysis
- Tracheostomy
- Enlarged adenoids/tonsils

Aspiration
- Secretions, food, liquid or foreign matter below the true vocal cords.
- Occurs during, after or before any swallowing phase.
- 94% of aspiration is silent.

Signs of Chronic Aspiration

- Coughing/choking during or after feeds

- Gurgly/wet breathing
- Respiratory infections
***If you see any of these symptoms you need to consider that the child has an
abnormal swallow and you will need to have an evaluation and modify the
feedings.
- Abnormal muscle tone
- Restrictive movement patterns
- Respiratory dysfunction
- Poor sensory awareness
- Damage to cranial nerves
- Inability to manage bolus
 Evaluation of Feeding Dysfunction

Interdisciplinary Assessment
Physician Social Worker
Dietician Special Education Teacher
Speech Pathologist Physical Therapist
Psychologist Nurse
Occupational Therapist

Specialty Disciplines
Gastroenterologist Endocrinologist
Pulmonologist Neurologist
Otolaryngologist/ENT Allergist

It is our job to understand what each of these team members contribute to a childs safety and
abilities during mealtimes and refer appropriately.

Instrumental Evaluation of Feeding

- Video Fluoroscopic Swallow Study (VFSS) or Modified Barium Swallow Study (MBS)
defines: nature and pathophysiology of swallow
- Identify adaptations that can be made for safer swallows
Advantages of VFSS
- IDs food textures that improve safer swallow
- A-P view can identify asymmetries
- Can ID risk factors i.e. pooling of food in pharynx
- Can monitor changes in swallow skills over time
Problems with VFSS
- Exposes child to radiation
- Represent a few swallows and not an entire meal. Cannot accurately say a child does
not aspirate.

Treatment for Oral Motor impairments

Treatment Includes:
 - Modify food textures- We will do these in lab
- Positioning
- Environment
- Mealtime methods

Positioning
Generally the optimal sitting posture is as follows:
- Head/neck- variable, but typically symmetrical and neutral
- Trunk- symmetrical, well supported
- Pelvis- can be various angles
- Knees and ankles- 90 degrees
- Feet- supported firmly

Head and neck position-

- Anatomically when your head is in extension it makes larynx and pharynx elevation more
difficult leaving the airway less protected.
- It does however allow gravity to transport the bolus to the pharnyx.
- When the neck is in flexion it narrow the laryngeal vestibule reducing laryngeal
penetration and aspiration

Trunk position
- Tilt position may be used for children that are unable to maintain their head position.
- Recline position may decrease the pressure on the abdomen for children with GERD

Positioning should:
- Reduce the impact of limiting physical patterns and facilitating more normal movement.

Positioning for infants

- Semi reclined
- Sidelying
- Enface

Positioning should facilitate social interaction

Environment
Quiet vs. distracting environments
- There are some children that eat within a distracting environment.
- Noise can be a concern especially with children that startle.
 - For many children, eating is difficult work and a less distracting environment is best.

Treatment for that are discussed in the class are:

- Oral motor dysfunction
- Sensory problems
- Behavioral difficulties

Treatment for oral motor dysfunction Will be covered in lab

Treatment for Sensory Problems

Hypo-reactive- Poor oral discrimination (Taste, smell, tactile)

- Associated with poor posture and low mm tone
- Diminished oral responses
o Poor lip closure
o Drooling

Treatment for hyporeactive

- Wake up the CNS! How could you wake up the CNS with food?
- Strong flavors, cold temps, colorful food, prop input

Hyper-reactive/ Oral tactile defensiveness- What are some of the feeding problems that
you might find with children that are hyporeactive?

- Exaggerated responses to: touch, taste, sound, textures, smell

- Children may have: emotional response to eating/feeding, food refusal, vigilance with
food, difficulty with oral care, transitioning to a higher level of food texture.

Treatment for hyperreactive: How could you calm down the CNS with food?
- Calm CNS, whole body approach, organized/consistent method, deep pressure, soft
voices, slow movements, blander food, consider temperature of food
Sensory Feeding Therapy
- Use the big 3s for sensory modulation-What are the big 3?
PROPRIOCEPTION, TACTILE, VESTIBULAR

Consider what input you are going to use for gustatory/olfactory input.
- Sweet, sour, bitter or salty
- Bland or bold tastes
- Smells are altering whether it is pleasurable or not.
- Smells are also linked with the limbic system and is tied to an emotional response.
 Behavioral difficulties at mealtimes

Behaviors can affect mealtimes by:

- Refusal of new foods
- Wanting a particular food everyday
- Acting out

Treatment for behavioral problems at mealtimes-What are some of the ways that the book
describes for treating a child with behavioral problems for feeding and swallowing?
- 1 food at a time, avoid power struggles, respect preferences, do not beg punish or bribe,
set a good example, prepare food in variety of ways, have child help in preparation,
select other foods with same nutrients, ignore undesirable behavior, attend to and
respond to desirable behaviors.

Working with children with supplemental feeds

- When it is found that a child is not safe to have foods by mouth they are considered non-
oral feeders.
- Children that can not have food by mouth may be allowed tastes. This is done with
extreme caution.
- A child that does not have an adequate swallow may not be able to tolerate an increase
in oral secretions such as saliva
- What happens when you put something sweet in your mouth?

Transitioning from tube feeds to oral feeds

- Tastes and food should be offered during gastrostomy feedings if safe.
- Always done under the supervision of a physician.
- There needs to be an established weight reserve.
- When deciding to transition a child to oral feeds
- Therapy must address the underlying problem first.
- Tube feedings may need to change from slow feeds over a long period of time.
- Tube feeding volume is decreased gradually.
- Mealtimes are offered prior to tube feedings.
- Tastes and food should be offered during gastrostomy feedings.

Self-Feeding Intervention
- Position-position-position!
o Must address underlying difficulties that impact self-feeding.
- Adaptive equipment if necessary
- May use mirror for children with poor body awareness.

Case Study Oral Motor

Mae is a 30 month old girl with Down Syndrome in an inclusive EI program. Mae has very poor
oral motor skills and is an extremely messy eater. She demonstrates a large amount of food
loss during eating and has difficulty drinking from an open cup. Throughout the day Mae
assumes an open-mouth posture and she wears a bib due to constant drooling. Maes parents
are aware of this situation and report they still give her bottles throughout the day because it is
easier and they are concerned that she is not getting enough nutrition. Mae was referred for OT
d/t her difficulties during snack time including inability to chew age-appropriate foods, inability to
perform lip closure on utensils/cups, and inefficiency of consuming food/drink.
Long Term Goals- for 6 months
1. Mae will improve oral motor skills as evidenced by independently consuming snack with
no food loss in trials.
2. Mae will demonstrate improved lip closure by independently drinking from an open cup
with no spillage in trials.
Problems addressed in the session: Jaw strength and cup drinking
Short Term Goals:
1. Mae will chew cut up foods when offered on lateral chewing surfaces adequately for
swallowing in 8/10 trials.
2. Mae will close her lips adequately with small sips from a cup with verbal cues in 3/5
trials.
Treatment strategy: Establish
Model of Practice: NDT, Biomechanical SI

Treatment Plan Rationale

Prone on scooterboard to propel self muscle tone

for 10 feet 5 times to pick up 5 pieces
of tea party set to play tea party with a
doll and bring to a table. Provide sensory input to alert nervous
system and muscles and prepare
Provide Mae with TMJ joint
mouth for eating
compression intermittently throughout
meal. muscle tone
Provide Mae resistive activity of
chewing gummy bears when placed on
lateral chewing surfaces. jaw strength

Provide jaw support and offer sips of

milk (pretend tea) from open cup.

jaw stabilization and control

 Note
03/12/14 10:00-10:30
S: Mae worked well in therapy room without distractions. Excessive drooling noted initially.
O: Mae was able to propel herself while in prone 10' in 3/5 times and then fatigued. Mae
responded well to joint compression of the TMJ no aversive reactions. Mae was able to chew
gummy bears when placed on alternating sides of chewing surfaces, but difficulty chewing all
the way through. Therapist provided maximal jaw stabilization as Mae drank from an open cup
with moderate spillage. Educated teacher and Mae about cues to use to decrease Maes
drooling and improve her oral motor control. The cue involves touching the chin with first digit
while closing the mouth and humming mmm. Mae copied therapist 2x during education of
cue.
A: Mae continues to require cues and maximum assistance by an adult during mealtimes to
improve her ability to participate in mealtimes.
P: Continue to work with family and teacher on improving consistency during mealtimes.
Continue to work on jaw strength and lip closure.
Jane Feedingqueen MS OTR/L 020111-1 Jane Feedingqueen MS OTR/L 03/12/1Case Study
Sensory
Miles is a three year old boy in an inclusive preschool program. He has been G-tube fed for
medical necessity the first few years of his life and is now being referred to OT d/t severe oral
hypersensitivity. Miles turns his head, gags, and cries during feeding activities. Miles will
explore food items with his hands if given prompts in a non-threatening environment, but will not
volitionally orally explore foods. Miles' mom reports she does not work on feeding with him at
home because it is too difficult. Miles becomes extremely agitated and demonstrates avoiding
behaviors when food or a toothbrush is brought to his mouth by an adult.
LTGs for 10 months
1. Miles will decrease oral sensitivity by as evidenced by allowing toothbrushing without
aversive behaviors in 3/5 trials.
2. Miles will decrease oral sensitivity by independently eating 10 spoonfuls of a non-
preferred food texture in 3/4 trials.

Problems addressed in the session: Miles as tactile defensiveness which causes food
refusals.

STG:
1. Miles will decrease oral sensitivity by orally accepting different foods presented on a toy
without aversive or avoiding behaviors in 4/4 trials.
2. Miles will decrease oral sensitivity by orally exploring NUK or toothbrush in trials
without aversive behaviors.
Treatment strategy: Establish
Model of Practice: SI

Treatment Plan Rationale

Wear body sock during calm and slow oral hypersensitivity

linear rocking on platform swing while
playing Simon Says.

Provide textured objects, teethers, oral hypersensitivity

vibrating toys, and play food and
tactile exposure and food acceptance
model bringing objects to mouth.
Encourage Miles to explore objects
with hands and bring them to his face
and mouth. oral hypersensitivity

Position Miles in seat and apply firm

pressure starting distally at arms and oral hypersensitivity and tactile
shoulders and work up to face.
exposure and food acceptance (SI)
 Scoop pudding onto table top while
encouraging him to explore with
hands.
oral hypersensitivity
Apply firm pressure to gums and
palate with gloved finger and nuk. Try
nuk and gloved finger with taste of
vanilla pudding on it.

Note
3/12/14 10:00-10:30
S: Miles demonstrated distress about coming to therapy and had difficulty transitioning from the
classroom.
O: Miles wore body sock on platform swing during slow linear swinging for 10 minutes to provide
deep pressure to prepare for tactile stimulation. Miles tolerated sensory input well with no
aversive reactions and appeared calm during transition to play area. Therapist modeled
pretend eating play food and provided visual and verbal and after 10 minutes he was able to
touch the toothbrush to his lips briefly. While in supported seating, Miles tolerated deep
pressure to body, but displayed distress when it was attempted to touch face. Activity was
discontinued. Played in pudding placed on his tray with visual and verbal cues. Miles did not
tolerate deep pressure massage to gums and pallet with nuk and gloved finger. He tolerated a
small amount of pudding placed on his lips and then he wiped it off.
A: Miles demonstrates severe oral tactile defensiveness and did not tolerate many of the
activities provided during session. Miles demonstrates distrust for therapist.
P: Continue with providing sensory input from outside of meals to establish rapport.

Jane Feedingqueen MS OTR/L 020111-1 Jane Feedingqueen MS OTR/L 03/12/14

 Case Study
Savannah is a five year old girl with CP in an inclusive preschool program. Savannah
demonstrates a strong extensor pattern. Savannah has a lot of feeding difficulties. She has
been displaying tonic bite reflex and forcefully biting down on toys and utensils brought to her
mouth. A strong tongue thrust and immature tongue movements including poor lateralization
have also been reported during oral activities. She is currently eating a pureed diet. After
observing Savannah it is also evident that she has abnormal tightness in her cheeks during lip
closure making it difficult to swallow a bolus.

LTGs for 10 months

1. Through the use of proper positioning, Savannah will decrease oral hypertonicity as
evidenced by a decrease tonic bite reflex 75% of the time in 4/4 trials.
2. Savannah will demonstrate tongue lateralization 10 times during her meal in trials.

Problems addressed during the session: Tonic bite and decreased tongue lateralization

STG:
1. Savannah will demonstrate decreased extension patterns while positioned with head in
neutral position and hips flexed to 90 degrees during mealtimes as demonstrated by 0
tongue thrust in 3/5 trials.
2. Savannah will demonstrate tongue lateralization when side of tongue is stimulated 5
times in 3/5 trials.

Treatment strategy: Establish

Model of practice: NDT biomechanical

Treatment Plan Rationale

Position Savannah in Rifton feeding head and trunk control and reduce
chair to encourage neutral head extensor tone (NDT and
position and provide trunk and biomechanical)
shoulder support as well as flexion at
the hips and knees.
tongue lateralization (Biomechanical)
Stimulate sides of tongue and mouth
with flavored and textured nuk brush safety concern of tonic bite and
tongue thrust (Biomechanical)
Provide room temperature pudding on
rubber coated spoon and place spoon
 to sides of the mouth Colder temperatures might increase
sensory input and stimulate a bite
reflex (SI)

Note
03/12/14 12:00-12:30
S: Worked with Savannah in cafeteria during lunch time. Cafeteria was loud and stimulating so
session was done in a quiet corner.
O: Positioning in Rifton chair with leg and foot straps to maintain LE flexion was effective in
reducing extensor tone and providing support. Savannah responded well to therapist using
textured nuk brush with slight mint flavoring to provide tactile stimulation to tongue to improve
tongue lateralization. Savannah bit down on nuk brush 2x during 10 minutes. Using teflon
coated spoon, Savannah bit down on spoon 3x during 10 minutes while room temperature
pudding was offered on alternating chewing surfaces.
A: Environment and hypertonicity contributes to poor feeding skills.
P: Continue to work on oral motor skills in a quieter environment.

Jane Feedingqueen MS OTR/L 020111-1 Jane Feedingqueen MS OTR/L 03/12/14

Modifying Food Textures Lab

Modifying liquids: May use thickening agent such as Thickenup or Thick & Easy (can even use
applesauce)
Liquids are classified as the following:

Thin liquids: Unthickened, such as water or juice. Common thin liquids include coffee,
tea, clear broth, clear juice, skim milk, 2% milk, and whole milk.

Nectar thickened: Should pour in a continuous stream without "breaking" into drops.
Common "natural" nectar thick liquids include nectar, tomato juice, and buttermilk.

Honey thickened: Sticks to the sides of a cup like honey. Pours very slowly. Liquids
include honey and cream soups.

Children who have a restriction to thin liquids should avoid ice cream, popsicles, and Jell-O as
these melt into thin liquids in the mouth.
Food textures

Texture Description

Food has a thin puree texture i.e. does not hold its shape on a plate or when
scooped
Thin
Puree There are no bits i.e. no lumps, fibers, bits of shell/skins, bits of husks, gristle or
bones
Cannot be eaten with a fork as it would drop through the prongs
Can be poured
May not be nutritionally complete

Food has a thick pureed texture

Thick There are no bits i.e. no lumps, fibers, bits of shell/skins, bits of husks, gristle or
puree bones
Will hold its shape on a plate or when scooped
Can be eaten with a fork
May not be nutritionally complete

Ground Food is soft, tender and moist

Pre
mashed
It is usually served with a very thick smooth sauce, gravy or custard i.e. a sauce
that holds it shape
There are no hard, tough, chewy, fibrous, stringy, dry, crispy, crunchy or crumbly
bits
May have to be moistened

Food is soft, tender and moist

Chopped It is usually served with a very thick smooth sauce, gravy or custard i.e. a sauce
that holds it shape
There are no hard, tough, chewy, fibrous, stringy, dry, crispy, crunchy or crumbly
bits
Cut-Up Food is cut up into bites sized pieces
Regular Food in its regular form

Adapted from the "Dysphagia Diet food texture descriptors (April 2011)

Helpful hints for preparing foods for puree

1. Foods that contain nuts, seeds or other hard particulates cannot be pureed.
2. Slurries may be needed for foods that are difficult to puree. A slurry is a mix of liquid and
thickener if needed that is poured over the food allowing it to become softer. Example
Oreo
3. Cut food into small chunks and will puree more evenly.
4. Hot foods puree better than cold.