There are many different reasons for a child to be referred to feeding therapy. These can range from oral motor issues, difficult meal time behaviors, impaired swallowing, tube dependence, and weight loss. One of the most common reasons for referral to a feeding therapist is that a child is having difficulty progressing to solid foods or not chewing.
What does poor chewing look like?
A child who is having difficulty with chewing might have these types of behaviors when eating at meal time:
• Gagging, choking or vomiting on lumpy bumpy textures and/or on solid foods.
• “Pocketing” or holding food in the mouth, often in the cheeks. Some children will hold solid foods for hours.
• Sucking on solid foods instead of biting and chewing. Often these children have very long meals with not a lot of food actually being eaten. This may result in poor weight gain.
• Swallowing food whole which may cause choking or difficulty swallowing.
• Spitting out or “expelling” the solid foods.
• Refusal to eat solid foods with preference for liquids and easy to manipulate foods such as purees or soft solids the child can mash with their tongue.
As a feeding therapist, one of things I tell the caregivers of children I work with is that in order for a child to eat efficiently, the child's meal consistency or texture must match their oral motor skills. If a child who can't chew is given a meal of solid foods, the child has three choices. The child can suck on the food, spit out the food, and/or swallow it whole. All of these options have obvious negative consequences. Often by providing the child with some mashed foods, home made purees, or high calorie liquids in the meal- we can get improvement with eating specifically caloric intake and more food in with less effort. And then, depending on the child's skill level, we would make suggestions as to the types of chewables foods are best, the number of bites the child can handle, or therapeutic strategies to improve the chewing pattern.
Typical development of chewing
Chewing is a complex motor pattern and a skill that in typical development takes two years or more for a child to move from sucking to manipulation of textured and solid foods using first a vertical chewing pattern and then rotary chewing movement. Oral motor development often co-occurs with gross motor milestones so as a therapist we look at these things together, especially in children aged birth to three years. Of course, there are always exceptions but we use the gross motor skill level to help determine where the child should be functioning orally.
0-7 months: Infants primarily use a sucking pattern for the first 6-7 months of life by sucking on the breast or bottle and then with acceptance of smooth purees via spoon feeding. With most children, we tend to start spoon feeding after a child has mastered some independent sitting skills. When a child accepts purees on a spoon, they are using a sucking pattern or in therapy terms a “midline” tongue pattern which means the tongue is in the middle of the mouth.
7-8 months: At this time, we begin to offer infants solids that dissolve or melt. The child will practice moving the dissolvable solid to the sides of the mouth on the gums with open mouth up and down biting called “munching” followed by sucking with a closed mouth. Gagging during this phase is common. Gagging to the point of vomiting is not common and might indicate some hypersensitivity. The child will use a sucking/munching pattern for months as they learn to move the solid laterally (to the side) for open mouth biting and manipulation.
8-9 months: As the child shows improving skills with the dissolvable solids, we begin to offer soft solids that can also be mashed with the tongue. Many children are beginning to crawl at this point. The child is moving into the vertical chewing phase which involves more tongue movement with lateral transfer of the solids to the gums/teeth, open mouth biting, some jaw shifting and then sucking. New chewers move between chewing and sucking for many months as they build their skills.
1 year: Many children take their first steps around the age of one. Concurrently, this is when we see chewing take off for most children. After the age of one, most children are able to handle a variety of chopped or diced solid food using the open mouth vertical chewing pattern. At this stage , they have more stamina and skill development to eat some harder foods and have more chewables in the meal. Many still receive some purees and formula or breast milk.
Two – Three years: From age two to three, children are moving from a vertical chewing pattern to more of an adult chewing pattern with rotary or semi-circular jaw movement and better tongue skills to move food in the mouth. A child reaches mature chewing around the age of three. It takes years of practice and motor skill development for a child to master the strength, motor planning, and stamina for mature chewing.
We tell caregivers that one of things we are looking for with our new chewers is open mouth chewing. Children that are learning to chew always chew with their mouth open. If a toddler is given a solid food and closes their mouth, they are often sucking or tongue mashing the solid food. We teach children to close their mouths for chewing usually around the age of four or older.
What if my child is not chewing?
Because it is a complicated skill to learn involving strength, stamina, and motor planning, it can take children who are not chewing a LONG time to learn this skill. How long will it take for a child who cannot chew to learn? That depends on several factors including readiness factors, the age of the child, their gross motor function, their GI tract and sensitivity, muscle tone and motor control, their willingness and desire for solids, and last but not least- practice. All of these factors can influence the transition from sucking to chewing. (If you want to read more on these specific factors, see this post.
Therapy for chewing
Therapy for chewing can take many forms but will consist of oral motor therapy to teach the individual components of chewing; simply these include lateral tongue movement and biting. This is done with placement of purees and solids in the sides of the mouth to encourage the tongue to retrieve the food, tongue exercises to develop motor patterns, and exercises to develop biting strength and coordination. We also incorporate gross motor exercises for strength and range of motion, particularly head control, upper extremity strength, core strength and trunk rotation. All skills which precede chewing in typical development.
Follow a developmental sequence of texture progression. All children start with a sucking pattern. What moves a child's oral motor pattern forward is practice eating. Most children move to chewing faster if they have a period of time eating easier textures, such as purees well. We don't recommend skipping that phase if you are a non-oral feeder.
Importance of weight gain and growth: It is important for the child to be growing and gaining weight well. Proper weight gain and growth should always be the first aspect of a feeding program to be addressed. All children function better with good nutrition.
In typical development, the skill of chewing takes two to three years to master fully mature chewing. No one can predict how long it will take a child to learn to chew in therapy but we know that it is a skill that will take time, patience, and daily practice. One of my blog readers posted that learning the skills to chew is a marathon not a sprint. I couldn't agree more.
Disclaimer: This post is meant to provide general information only and should not be used for medical advice or in replacement of evaluation with a trained professional. Each individual’s situation is unique and any treatment should be done in consultation with a medical professional.
Krisi Brackett is a speech pathologist with specialization in pediatric feeding and swallowing issues. She has been practicing for over 20 years and currently serves as Co-Director for the UNC Pediatric Feeding Team, a multidisciplinary feeding team, at UNC Hospitals, Chapel Hill, NC, USA. She presents workshops on feeding and swallowing disorders across the USA and is a contributing author for “An Integrated Approach to Feeding Intervention” (chapter 1) in Pediatric Feeding Disorders: Evaluation and Treatment, Therapro 2013. She has also practiced feeding intervention in early intervention and private practice. She writes the popular pediatric feeding blog, www.pediatricfeedingnews.com , is adjunct faculty at the Division of Speech and Hearing Sciences, UNC-Chapel Hill and a member of the UNC based pediatric feeding research group, The Feeding Flock. She has been a member of ASHA, the American Speech and Hearing Association since 1993 and served on many committees pertaining to pediatric feeding issues.