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A Guide to Feeding Young Children with Special Needs
Project CHANCE
by the Arizona Department of Health Services, Offices of Nutrition Services

Section 3: Child Development and Oral Motor Skills

Goal:
Describe to the early childhood program staff ways to help a child develop oral motor skills, how food texture relates to that process, and proper body positioning when feeding a child with special health care needs.

Learning Objectives:

  1. Identify normal sequence of development of oral motor skills.
  2. Describe methods to develop oral motor skills in a child with special needs.
  3. Describe the appropriate textures of food for the different levels of oral motor skill development.
  4. Describe general guidelines for proper positioning of a child with special health care needs during feeding.

INTRODUCTION

A child's developmental readiness determines when solids should be introduced, the texture of the food, and how feeding is done. It is important to be aware of a child's developing mouth patterns (oral motor skills) and hand and body control so that you know the appropriate food texture and feeding techniques to use.

The following table shows the typical development of oral motor skills, hand and body control, and the relationship to food textures and how the child eats. The approximate age at which development occurs is given as birth to 11 months, but keep in mind that all children develop at their own rate. In addition, these skills may develop more slowly in a child with a disability — a three-year-old with cerebral palsy may just be reaching the developmental stage of learning to self-feed with a spoon.

 

Sequence of Infant Development and Feeding Skillsin Normal, Healthy, Full-term Infants

AGE

Oral Motor Skill

Hand and Body Control

Child Can:

Birth through 5 months

  • Suck/swallow reflex
  • Tongue thrust reflex
  • Rooting reflex
  • Gag reflex
  • Poor control of head, neck, trunk
  • Brings hand to mouth around 3 months
  • Swallow liquids but pushes most solid objects from the mouth
4 months through 5 months
  • Draws in upper or lower lip as spoon is removed from mouth
  • Up-and-down munching movement
  • Can transfer food from front to back of tongue to swallow
  • Tongue thrust and rooting reflexes begin to disappear
  • Gag reflex diminishes
  • Opens month when sees spoon approaching
  • Sits with support
  • Good head control
  • Uses whole hand to grasp objects (palmer grasp)
  • Take in a spoonful of pureed or strained food and swallow it without choking
  • Drink small amounts from cup when held by another person, with spilling
5 months through 9 months
  • Begins to control the position of food in the mouth
  • Up-and-down munching movement
  • Positions food between jaws for chewing
  • Begins to sit alone unsupported
  • Follows food with eyes
  • Begins to use thumb and index finger to pick up objects (pincer grasp)
  • Begin to eat mashed foods
  • Eat from a spoon easily
  • Hold a bottle independently with one or both hands
  • Drink from a cup with some spilling
  • Begin to feed self with hands
8 months through 11 months
  • Moves food from side-to-side in mouth
  • Begins to curve lips around rim of cup
  • Begins to chew in rotary pattern (diagonal movement of the jaw as food is moved to the side or center of the mouth)
  • Sit alone easily
  • Transfers objects from hand to mouth
  • Begin to eat ground or finely chopped food and small pieces of soft food
  • Begin to experiment with spoon but prefers to feed self with hands
  • Drink from a cup with less spilling
10 months through 11 months
  • Rotary chewing (diagonal movement of the jaw as food is moved to the side or center of the mouth)
  • Begins to put spoon in mouth
  • Begins to hold cup
  • Good eye-hand-mouth coordination
  • Eat chopped food and small pieces of soft, cooked table food
  • Begin self-feeding with help

USDA/Food and Nutrition Service. Infant Nutrition and Feeding. 1993

Sucking and swallowing are basic survival skills for infants; chewing follows after certain developmental stages. Of course these skills are important for nourishment, but they are also important for the future progress of speech.

As simple as it may seem to suck, swallow, or chew, it takes a lot of coordination of the mouth, jaw, and throat. A child may have trouble with this coordination, and therefore with one or all of these skills. She will need help and encouragement from you until she learns how to suck, swallow, and chew on her own. Be a part of the "feeding team" - with the family and health care specialists - that makes the plan to help the child develop oral motor skills and progress in feeding milestones.

SUCKING

If a child has a weak suck:

 

You can help her develop a stronger sucking motion by:

A good sucking pattern is an important step towards good speech patterns which come later.

SWALLOWING and FOOD TEXTURE

Some children have trouble with swallowing. They may gag and cough when eating, and may drool throughout the day. A child with a swallowing problem may be working with a therapist to improve swallowing skills - and may need certain food textures to allow for safe swallowing.

"Texture" is how smooth, lumpy, thick or thin the food is. The following table describes different textures, examples of foods, and tells what the child can usually do when she is able to handle the texture.

FOOD TEXTURE AND EATING SKILLS

TEXTURE DESCRIPTION EXAMPLE CHILD CAN:
Pureed and blended table foods, commercial baby food Food forms a paste or thick liquid; use strainer or blender and blend to a paste, add liquid for desired consistency Cream of Wheat, pudding, applesauce; blended meats, vegetables and fruits


Suck and swallow; take food from spoon with lips; swallow thickened puree and not gag
Mashed lumpy



Food forms a heavy bolus; food is blended or mashed with a fork; food retains some texture and consistency

Mashed potatoes; mashed bananas and other soft fruits; mashed hard cooked eggs; mashed carrots or squash

Swallow without gagging; close lips while swallowing food; remove food from spoon with lips; up-and-down munching movement
Ground



Food ground in food chopper, not blended; food retains some lumps for chewing foods; should be easy to chew

Crumbled/ground meat; scrambled eggs; cottage cheese; small pieces of toasted bread crusts; crackers broken into small pieces

Begin to chew in rotary pattern


Chopped


Cut with knife into bite-size pieces; no raw hard foods (carrots)

Chopped fruit (soft raw or cooked); chopped meats; chopped cooked vegetables Do rotary chewing

Regular

Cut up food or leave whole

All foods

Close lips and keep food in mouth; bite through food

The occupational therapist or speech pathologist on the feeding team can tell you what textures the child with swallowing problems can have. You can change the texture of many foods to meet the needs of the child.

Along with grinding, mashing, and pureeing foods, you may also need to thicken or thin them. Listed on the following page are some examples of what you can use:

 

To thicken add:

  • Infant cereals
  • Wheat germ
  • Instant cream of wheat
  • Pureed fruit or vegetable
  • Powdered milk
  • Unflavored gelatin
  • Ice cream
  • Yogurt
  • Pudding
  • Cracker crumbs
  • Rice Krispies® crumbs
  • Mashed potato flakes
  • Bread cubes
  • Commercial thickener (such as Thick-It©)
  • Applesauce

To thin add:

  • Water
  • Liquid milk
  • Formula
  • Juice or pureed fruit
  • Soup broth
  • Pureed vegetables
  • Mayonnaise
  • Ketchup




Make sure the texture modifier matches the flavor of the food, such as:

It is important to find out how thick/thin the food needs to be. Have someone show you how to change the texture of the food. Keep instructions posted in the food preparation area on how much thickener or fluid is needed to modify the texture. This will ensure proper and consistent food preparation.

Tounderstand what a child experiences, try textured food (such as pureed meat or a thickened liquid) and see how it feels in YOUR mouth!

Introducing New Textures

A child's diet should include foods with a variety of textures to encourage mastering the skills of swallowing and chewing. With the direction of the feeding team, be sure to help the child with special needs advance to more texture in her food.

When offering a new texture to an infant or child, offer a few spoons of the familiar texture first, then the new texture. For example, when going from pureed to mashed/lumpy offer blended carrots first - then fork-mashed carrots. This allows the child to:

Textures Which Commonly Cause Problems

If a child needs ground, mashed or pureed food, you can still use the CACFP meal pattern to develop menus for your program. Adding a few extras to the thin liquids to thicken them, and substituting a few foods from the regular menu will provide a balanced meal for the child with special needs.

Here is an example of a regular menu that has been modified to a pureed menu:

 

Regular Menu Pureed Menu

Breakfast
Juice, fruit, vegetable
Cereal or bread
Milk

Orange wedges
Oatmeal with raisins
Milk

Orange juice, thickened with tapioca*
Oatmeal and raisins pureed with milk
Milk (1/2 cup) blended with 1/4 cup dry baby rice cereal

Snack (any 2 of the 4)
Milk
Vegetable, fruit or juice
Meat or alternate
Bread or cereal


Milk
Muffin
or
Yogurt
Peaches

Milk blended with dry baby rice cereal
Muffin - puree on low speed, adding warm milk

Yogurt
Peaches - pureed

Lunch or Supper
Meat or alternate
Vegetable and/or fruit
Bread
Milk


Tacos - corn tortilla, ground beef, lettuce, cheese
Tomato wedges
Milk
Banana half

Pureed ground beef
Cooked corn meal
Pureed tomato
Milk blended with dry baby rice cereal
Pureed banana

 


GAGGING

Gagging and choking can either be a sign of aversion to something new and different, or a sign that the child is having trouble swallowing. Listed below are some common causes:

If gagging and choking are chronic problems, it must be followed by a health care specialist. Be sure to find out why a child has swallowing problems, and what you need to do when feeding her.

Even with good oral motor control, choking can happen to any child. Here are some foods to avoid and food preparation techniques to help prevent choking:


CHEWING

When a child chews, large pieces of food are broken into smaller pieces and softened so that the food can be easily swallowed. Learning to chew may be difficult for the older child who has been on pureed foods for a long time. However, to keep the child on pureed foods when she should be advancing to more textured foods (determined by the health care specialist) will restrict her oral motor and speech development.

When a child is learning the skill of chewing, be sure to offer foods which are easy to chew.

Easy to Chew Foods

 

Meat/Meat Alternate:
  • Beans - baked, refried, boiled
  • Beef - ground, hamburger sloppy joe
  • Grilled cheese sandwich
  • Cheese - sliced, cubed
  • Chicken - chow mein, chopped with noodles, chicken salad
  • Cottage cheese
  • Eggs - scrambled
  • Fish fillet - baked
  • Tuna salad

Fruits

  • Applesauce
  • Bananas
  • Peaches - peeled
  • Pears - peeled
  • Cantaloupe
  • Stewed prunes

Bread/ Bread Alternate:

  • Bread - day old (easier to chew), cut up, toasted
  • Cold cereal with milk
  • Hot cereals
  • Muffins, pancakes, waffles cut up
  • Macaroni with cheese
  • Noodles - buttered
  • Flour tortilla
  • Rice casserole
  • Hamburger bun

Vegetables

  • Green beans - cooked, cut up
  • Cooked carrots
  • Cucumbers - peeled and chopped
  • Potatoes mashed, au gratin
  • Spinach - cooked
  • Tomatoes - cooked, raw, cut up

To promote chewing:


FEEDING

Have a family member or occupational therapist/speech pathologist show you how to feed the child; then have them watch as you feed the child - this will help build your confidence. It will also ensure proper, safe, and consistent feeding techniques for the comfort of the child.

Feeding tips:

Other issues:

REMEMBER

The goal of feeding any child is to progress to coarser textures to help with oral motor development. Keep in mind that:


POSITIONING

Determining the proper feeding position for a child with special needs is as important as the careful planning for proper foods and textures.

A therapist should work with the child and family to find the best feeding position according to the child's needs. Have the family or therapist show you what position the child should be in for feeding, and how to get the child into that position - including any necessary supports needed (rolled towels, special chairs).

There are many good feeding positions, and each child has specific needs - but there are some general guidelines for positioning a child:

For you to experience how body position affects eating, try different positions the next time you eat - slouched, leaning back, feet dangling, head tilted back. See what effect it has on your ability to chew and swallow!


Selected References

Feeding and Caring for Infants with Special Needs. S. Ersted, editor. Minnesota Department of Health Services for Children with Handicaps and Health Education Section, 1987. To order contact: AOTA Products, 1383 Piccard Drive, P.O. Box 1735, Rockville, MD 20805; (301) 948-9626.

Feeding and Nutrition for the Child with Special Needs: Handouts for Parents. M. Dunn Klein and T.A. Delaney. Therapy Skill Builders, 1994.

Food. Nutrition, and the Young Child. J.B. Endres. Prentice-Hall, 1993.

Meals without Squeals: Child Care Feeding Guide & Cookbook. C. Berman and J. Fromer. Bull Publishing Company, 1991.

"Nutrition Care for Children with Developmental Disabilities." A series of brochures. To order contact: United Cerebral Palsy, 2430 11th Avenue North, Birmingham, AL 35234; (205) 251-0165.

Nutrition and Feeding of the Handicapped Child. I. Crump, editor. Little, Brown, and Company, Inc., 1987.

Nutrition and Feeding for Persons with Special Needs: A Practical Guide and Resource Manual. Nutrition Education and Training Program, South Dakota Department of Education, Child and Adult Nutrition Services. 1992. To order contact: Child and Adult Nutrition Programs; (605) 773-3413.

Nutrition in Infancy and Childhood. P.L. Pipes and C.M. Trahams. Times Mirror/Mosby Publishing, 1993.

Pediatric Nutrition in Chronic Diseases and Developmental Disorders: Prevention. Assessment and Treatment. S.W. Ekvall, editor. Oxford University Press, 1993.

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