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Feeding

Whole-Child Feeding Therapy – The 4 Areas to Look for Maximum Progress

People underestimate the complexities of feeding disorders all too often. I have had too many children come to me who have been in therapy for YEARS with minimal progress. Parents are desperate, children are malnourished, and everyone. is. frustrated. The following are the 4 areas of feeding that must be evaluated and addressed in EVERY CHILD diagnosed with oral phase dysphagia. Heck, let’s go ahead and look at this even if a child is only considered a “picky eater.”

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1. Medical

If a child has any underlying, unaddressed, medical concerns that are related to their feeding, this *must* be addressed first and foremost. Perhaps not before beginning therapy, but it certainly needs to be a top priority.

Here’s what we are looking for:

  • food allergies (known or unknown)
  • history of (or current) feeding tube
  • strong gag reflex
  • GERD or history of reflux

 

Questions to ask during an evaluation:

  • What is your child’s favorite drink? (there is a correlation between children who LOVE water/only drink water and reflux)
  • How often does your child have a bowel movement? (should be at least once a day)
  • What is the consistency of their bowel movements? (should be fluffy- not runny or hard)
  • Do they have a current GI or dietician that is following their case?
  • Is their pediatrician concerned with their weight?
  • Do they have sour breath? (a sign of reflux)
  • Do they burp often after eating? (a sign of reflux)

 

Most of this boils down to this: if the child doesn’t feel good, they are less likely to want to eat or be hungry. Any concerns in this area warrant a call to their pediatrician, a GI referral (preferably one who specializes in children with feeding disorders), and possibly a referral to a dietician.

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2. Behavior

This, in my opinion, is very tricky to sort through. To the untrained eye, every refusal may look behavioral. This is a chicken and the egg situation- we may have behaviors because the kid is so scared of having to eat a food their body can’t handle (for sensory or motor reasons)… BUT in order to work toward our sensory and motor skills… we have to overcome the behavior. It’s enough to give anyone a headache.

Here’s what we are looking for:

  • spitting, throwing, or refusing food
  • cryings or tantrums at mealtime
  • requiring a distractor (i.e. iPad) at meals
  • eating differently with certain people or in certain settings

Here’s the big picture: we need to make therapy FUN and break it down into the tiniest steps possible. I used to be very anti-toy/reinforcement during therapy meals but let me tell you… once I embraced the power of 1:1 reinforcers, my kids started making much faster progress AND we were able to quickly fade the toy reinforcers. This trick is helpful even for kids with limited receptive language.

Questions to ask during an evaluation:

  • How does your child respond to non-preferred foods?
  • How do you feel at mealtimes?
  • How does your child feel at mealtimes?
  • What does meal time look like at home?

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3. Sensory

Enlist your OTs as needed here. A great way to sort out what sensory issues your kiddo may be fighting through is to take a thorough food inventory and look at patterns. Do they leave out whole categories of food related to temperature, texture, taste, color, shape, size, or smell? If so, food play may be your best friend. When we make it FUN, it’s no longer scary. I made a resource you can find HERE that encourages art projects and silly games and competitions during therapy meals. One pro tip- kids are MUCH MORE LIKELY to interact with a food when they know it’s about to go away. You can employ a cleanup routine to help with this (example: we “kiss our food goodbye” before throwing away).

Here’s what to look for:

  • refusing entire categories of food
  • limited food repertoire
  • strong brand preferances
  • refusing to eat foods that touch each other
  • refusing to touch or explore a food

 

Questions to ask during an evaluation:

Basically, get a very very thorough food inventory!

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4. Oral Motor

Having the skills to safely consume foods is critical as well. This is what we’re building up to… but we can’t work on chewing skills if the kid doesn’t allow the food in his or her mouth. Parents often don’t realize their child can’t chew appropriately or lateralize their tongue.

Here’s what we’re looking for:

  • poor lip closure or latch
  • weak sucking or chewing skills
  • overstuffing or pocketing food
  • limited tongue movement
  • immature chewing skills
  • difficulty transitioning from bottle to table foods

 

Questions to ask during an evaluation:

Don’t rely on a parent interview to give you the information you need here. The priority is for you to look for oral scatter, overstuffing, pocketing, swallowing food whole, and palatal mashing to name a few. Questions that might help:

  • Does your child ever have food left over in their mouth after meals?
  • Does your child choke while eating? (if liquid- be particularly cautious of aspiration and refer for FEES or MBS) (if solid- check for over-stuffing)
  • Get a thorough food inventory. (Leaving out entire categories of foods is another indicator of poor oral motor skills. Foods that require a mature rotary chew include non-processed meats/steak, raw vegetables, fruit with the skin).
  • Does your child eat oranges or grapes? (If yes, ask about if they eat it whole or spit the skin back out. If they cannot chew the skin, they may just suck out the juice.)

 

Tongue thrust may also be present during feeding. If so, you can check out this blog post for further information! If they’re thrusting on foods, they’re probably looking at some articulation therapy as well.

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And there you have it!

Thorough case histories and parent interviews are your friend. Make sure you are watching very closely how the child interacts with foods, chews food, swallows food, and even how they behave after they’ve finished eating. Don’t hesitate to reach out to their pediatrician, nutritionist, previous therapist, or  stinkin’ dog walker if you need to. We need the full picture and parents often don’t realize just how important little details can be- so ask ask ask!

For a nice breakdown of the 4 areas of feeding (perfect for a parent handout!) click the image below:

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Please feel free to reach out to me with any questions or comments! The best way to get a response is to DM me on instagram @SpeechyThings

Thank you for reading!

-Lindsey

Feeding, For Parents, Little Friends

Why Babies Mouth and How We Can Encourage

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“Did your child mouth as an infant?”

I ask this question all the time to the parents of kiddos with severe speech delays, picky eating habits, and other oral motor deficits.
More often than not, the answer is “not very much” or a flat out “no.”

Sounds like a dream, right? A baby who isn’t liable to choke on any little piece of who-knows-what lying on the floor? Jackpot!?

F A L S E

Why Mouthing Is Important:

Mouthing helps babies explore their world from a sensory and oral motor standpoint. They are learning about textures, tastes, and temperatures that will provide them with a solid foundation to move on from purees to solid foods (get it?) and avoid a picky eating rut. Additionally, they will begin to move their tongue and jaw in new, fun, and interesting ways. These movements will later develop into a mature chewing pattern that will allow them to eat a healthy variety of solid foods and help them produce lovely consonant sounds. As if all that wasn’t enough reason to encourage mouthing… it also helps the baby’s gag reflex move from the front to the back of their mouths.

Mouthing starts with the rooting reflex. This reflex is innate from birth and allows an infant to turn and attempt to suckle anything  that touches its face. The rooting reflex begins to diminish around the age of 4 months. At this same time, babies begin to gain the ability to bring their hands to their mouth. This is the opening of our mouthing window.

While it may be extremely convenient to not fear for your child’s safety due to the little babe putting ev.ery.thing. in his or her mouth… it may bite you later.

So what can we do?

  1. Provide lots of safe toys to mouth and gnaw on. You may even go as far as modeling what to do with these objects. That’s correct, adult reading this. I want you to put baby toys in your mouth. Lick and chew and move them around. Let that baby watch what to do.
  2. Make it a game. Think “puppy dog” and be silly so baby laugh and think its a fun game. Maybe they’ll be more willing to join in.
  3. Add some flavor. Try dipping an easy-to-wash toy in a juice or favorite puree to increase interest for the child.
  4. Make it cold. Place a toy in the freezer and see if it makes it more enjoyable. Again, we’re thinking about increasing sensory information.
  5. Provide texture. (sensory sensory sensory) We want bumpy toys. Soft toys. Squishy toys. ALL the toys! Bonus points for the language opportunities here.
  6. When your baby explores (safe) objects with their mouth, give praise. Make it a pleasurable experience and they are more likely to repeat their actions.

 

 

Some great options for mouthing can be found at your local retailers:

 

The Boon PULP Silicone Teething Feeder allows you to place a variety of flavors for your baby to safely explore and enjoy. Perhaps a juicy piece of watermelon or a frozen peeled grape? Yum!

 

 

 

A cute teething necklace like this one by BEBE by Me is another great option – you can’t lose it!

 

 

 

This nuby Banana NanaNubs gum massager is another adorable way to get your baby mouthing and ready for tooth-brushing. Here is the texture we’re looking for!

 

 


Perhaps my favorite is a good ol’ fashioned hard munchable. The key here, and this is very important, is that this is something the baby CANNOT chew or break off yet. The purpose at this point is only for sensory and oral motor exploration. Celery sticks work great too!

 

 

A few things to remember…

We never want to force, but we do want to encourage. A cry or a cold shoulder today could be a timid attempt to mouth tomorrow. Keep exposing the child to mouthing and be patient. Keep an eye out for little signs that they are becoming interested and try again soon.

If you are a parent reading this, it is always a good idea to reach out to a local Speech Language Pathologist for any concerns you may have with your child’s speech, language, and/or feeding. For more information, you may be interested in these parent handouts for late talkers.

 

Of course, safety is always first.

Please be sure that an adult is always present and watching closely as these options are explored. Use good common sense, folks. But we DO need that baby to learn all the awesome things their little mouth can do when it gets movin’!

 

Happy Mouthing, Speechy Friends!

-Lindsey

Articulation Therapy, Feeding

Frontal Lisps

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We can talk about “hiding our tongue” and keeping “tight teeth” ’til we’re blue in the face… but for some kiddos it seems that pesky frontal lisp just WILL. NOT. GENERALIZE. into a crisp, beautiful /s/. Why? Because the way the tongue of many frontal lispers moves is different and, to be honest, disordered all day every day. Often times, they have an immature swallow pattern. If you watch them eat, you will see that little tongue peep out more than it should.

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We see a huge correlation between frontal lisps and kiddos who have (or had) prolonged usage of sippy cups, pacifiers, and thumb-sucking. Their swallowing pattern got stuck a little too close to the suckle stage and they continue to use a tongue-thrust pattern to swallow. We swallow about 600 times a day. That means every time our kiddos clear their saliva they are reinforcing their frontal lisp.
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Furthermore, you will notice our kiddos have a low at-rest posture for their tongue. I like to joke that my superpower is being able to identify people who used to have a lisp just by watching them speak for a few seconds. Lispers tongues hang low in their mouth – you can check out what I mean by watching THIS video.

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SO WHAT CAN WE DO ABOUT IT?

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Before I start articulation therapy with any of my frontal lispers… we do a few things.

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1. Nose Breathing

Ensure that your kiddo is a nose breather. Perform an oral mech and check for enlarged tonsils. Ask about seasonal allergies. Refer accordingly. Mouth-breathing promotes a low, forward resting posture of the tongue.

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2. No more sippy cups

Or thumb sucking. Or pacifiers. Or finger sucking. Cup drinking and straw drinking only, please.

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3. Make sure their tongue tip can elevate to their alveolar ridge.

Some kiddos just haven’t figured this out yet. If you need some help getting tongue-jaw dissociation, take the jaw out of the equation by having them bite down on something that well help prop open their mouth. (My favorite is to stack a few popsicle sticks and tape the together. It’s cheap and easy to replicate at home.) This will stabilize their jaw and allow them to put all their focus on getting that tongue in position. You can always add a tactile cue by putting some sour spray or ice cream on their alveolar ridge. I find kiddos don’t need these cues for very long once they figure out where their tongue should be. We need to be able to elevate our tongue tip to swallow properly, to produce appropriate alveolar phonemes, and even to get a good clear /s/.

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4. Tongue checks.

Have the kiddo engage in a silent activity- be it iPad time, coloring, building blocks, or anything in between. Periodically do a “tongue check” to see that they are keeping their tongue tip elevated to their alveolar ridge. We are trying to change the resting posture of their tongue here. For a tongue check freebie, click here.

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5. Feeding therapy.

If you watch a frontal lisper eat, you will likely see that tongue sneak out during or after their swallow on most food consistencies (liquid, puree, crunchy, etc). They will tell you they are just licking their lips- nope. Target a mature swallow in feeding therapy- and consider referring out if you are not trained in feeding. Again, we swallow 600 times each day!

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6. Look beyond the /s/

Watch their tongue on all alveolar sounds. There is an awfully good chance that if they are lisping on /s,z/ sh, ch, j… that /t,d,n.l/ aren’t correct either. Watch close and remember to follow a developmental pattern when targeting phonemes.

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7. Consider an appliance.

If you are signed up for our newsletter then you have already heard about these awesome appliances. Think of it as a tiny speech therapist in their mouth 24/7. The idea is that they receive speech and feeding therapy to learn how to place their tongue at the alveolar ridge for their swallow and for all alveolar sounds. This little bead serves as a warning that their tongue is going too far forward.

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And there ya go!
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Just some food for thought, friends. There may be so much more going on than just that pesky /s/ sound. We want to be sure to treat the whole child and hopefully this post will shine some light on your students. Once  you’ve addressed these concerns, you’ll be ready to kick some articulation booty and get them cookin’ with some drill work and generalization activities. Have fun, speechy friends! Conquer the frontal lisp!

-Lindsey

(puppy photo credit: Marion Michele via unsplash.com)