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
Oral Motor Skill
Hand and Body Control
Birth through 5 months
|4 months through 5 months||
|5 months through 9 months||
|8 months through 11 months||
|10 months through 11 months||
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.
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.
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
|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
swallow; take food from spoon with lips; swallow thickened puree
and not gag
a heavy bolus; food is blended or mashed with a fork; food retains
some texture and consistency
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 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
knife into bite-size pieces; no raw hard foods (carrots)
||Chopped fruit (soft raw or cooked); chopped meats; chopped cooked vegetables||Do rotary
food or leave whole
||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:
To thin add:
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!
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:
Have an opportunity to become familiar with the new texture without becoming overwhelmed or physically tired because she is dealing with a new texture.
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|
Oatmeal with raisins
thickened with tapioca*
(any 2 of the 4)
with dry baby rice cereal
1/4 cup tapioca
32 ounces liquid (fruit juice, milk, water)
Measure 4 ounces of cold liquid in a container. Add 1/4 cup tapioca to the cold liquid and set aside. Bring remaining 28 ounces of liquid to rapid boil. Add cold liquid/tapioca to the boiling liquid and stir while it thickens. Thick liquid should be OK in the refrigerator for a few days if it gels, just add a little liquid and mix.
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:
Cook foods until soft enough to easily pierce with a fork.
Cut foods into small pieces or thin slices that can easily be chewed.
Cut round foods like cooked carrots into short, thin strips rather than round pieces.
Grind or mash and moisten food for young babies.
Remove all bones from poultry, fish, and meat.
Remove skins, pits, and seeds from fruit.
Avoid nuts or seeds (such as sunflower or pumpkin), unless ground finely or chopped.
Avoid plain peanut butter - always put on bread or crackers.
Avoid popcorn, grapes, and hot dogs.
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
Bread/ Bread Alternate:
To promote chewing:
Introduce lumpy foods gradually to begin the chewing motion. Start with mashed/lumpy foods and slowly progress to ground texture.
Sprinkle crumbled graham cracker pieces on pudding, leave lumps in hot cereals and puddings when cooking them.
Give the child foods to bite through, such as crackers, even if she spits them out - it helps develop jaw control for chewing.
Give the child enough time between bites to become used to the texture change, and to experiment and practice the new chewing skills.
Be sure to encourage the child as the chewing patterns develop.
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 a child, gently place the spoon on the middle of the tongue.
A little bit of pressure to the tongue may help the child keep the
tongue in her mouth. Give her time to close her lips around the spoon
and remove the food from the spoon by herself - do not scrape the
spoon on the top teeth to remove the food.
If a child
has problems with vision, be sure to let her know the spoon
is coming and what is on the spoon. Touch the spoon to her
lower lip first so she will get a little taste of the food.
A child may need help with jaw support or/and lip closure when feeding. A therapist, or the family, can tell you if a child needs help in these areas and can teach you the skills you need.
A child may stiffen when the spoon comes near her face too suddenly. This may be a reflex instead of a refusal of the food. Let the child know the spoon is coming, move the spoon slowly towards the mouth, and bring the spoon in lower than the mouth to keep the chin tucked in.
A child may bite down on the spoon - she may do this because she dislikes the food, wants to slow down the feeding, or she wants to gain more control over her jaw. It may also be a bite reflex over which she has no control. Be sure to check with the feeding team specialist if this is a problem area.
Even though a child gets messy when eating, too much face wiping may overstimulate the child and distract her from eating. For other children, wiping the face may be needed to keep them awake during mealtime. Always wipe towards the lips.
Look for stress signs - they may mean the child is not positioned properly or the feeding is too fast. Examples of stress signs are turning the head away, rapid breathing patterns, and even sounds or words. Try to find out what the problem is.
If an older child cannot speak, a communication board may be helpful. This board can have pictures and words of simple directions such as "drink," "eat," "more," "done." The child can either point with her hand or her eyes.
The goal of feeding any child is to progress to coarser textures to help with oral motor development. Keep in mind that:
Some children with special health needs may be on pureed or strained foods for an extended period of time.
Younger children seem to accept new foods with more texture (mashed, ground, chopped) better than older child.
Advancing gradually to coarser textures will allow the child time to become accustomed to the texture, and with practice, learn how to handle these foods. Be sure to work with the family and feeding team on progression of textures.
A child may need to be encouraged to try new foods and textures. Serve a small amount of a new food along with a favorite food; offer new food when the child is hungry and in a good mood.
Good taste, proper temperature, and appropriate texture of the food will help stimulate chewing and swallowing.
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:
your hands, and clean the child's hands and face, before
positioning the child.
body should be upright in a sturdy seat.
should be upright and slightly forward with chin tucked in.
be forward and rest comfortably on the tray or table.
be bent in a sitting position
(about 90 degrees). You may
need to use a seat belt or towels
tucked around the child to keep
her in position.
Feet should rest flat on a firm surface. A covered book or box can be used to support the feet.
a special chair is needed to give the child support and help
keep her in position.
Take a picture of the child in her proper sitting position, from both the front and the side, and hang it near where the child is fed so anyone involved in feeding her can see it.
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!
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.
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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.