From Pre-Feeding Skills: A Comprehensive Resource for ... · Evaluation of Respiratory Function . ....

Contents

ix

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

The Growth of Knowledge and Understanding . . . . . . 1

The Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

The Journey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Strategies and Techniques . . . . . . . . . . . . . . . . . . . . . . . 3

Keys to Learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Chapter 1 Foundations for a Mealtime . . . 7

What Is a Mealtime? . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Reflections on a Mealtime . . . . . . . . . . . . . . . . . . 7

Where Did You Eat? . . . . . . . . . . . . . . . . . . . . 7What Did You Eat? . . . . . . . . . . . . . . . . . . . . . 7With Whom Did You Share the Meal? . . . . . 8

Purposes of a Mealtime . . . . . . . . . . . . . . . . . . . . . 8Communication . . . . . . . . . . . . . . . . . . . . . . . 8Socialization . . . . . . . . . . . . . . . . . . . . . . . . . . 8Giving and Receiving Love . . . . . . . . . . . . . . 8Sharing Personal Values Related to Eating . 9Sense of Family, Culture, and Community . 9Celebration . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Physical Growth and Health . . . . . . . . . . . . . 10Sensory Exploration . . . . . . . . . . . . . . . . . . . 11Relaxation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Habit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Break in Routine . . . . . . . . . . . . . . . . . . . . . . 11

Aspects of Nourishment at Mealtimes . . . . . . . . . 11I Feel Nourished at Mealtimes When . . . . . . 12I Do Not Feel Nourished When . . . . . . . . . . . 12

Creating Nourishing Mealtimes for Children and Families . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Chapter 2 Mealtime Influences . . . . . . . . . . . 15

Identifying and Understanding Mealtime Influences . . . . . . . . . . . . . . . . . . . . . . . . . 15

The Influence of Beliefs . . . . . . . . . . . . . . . . . . . . 16The Influence of Culture . . . . . . . . . . . . . . . . . . . 17The Influence of the Parent’s History . . . . . . . . . 18The Influence of the Child’s History . . . . . . . . . . 19The Influence of Family Dynamics . . . . . . . . . . . 20The Influence of Socioeconomic Factors . . . . . . 21

The Influence of the Child’s Health . . . . . . . . . . . 22The Influence of the Child’s Developmental

Skills and Needs . . . . . . . . . . . . . . . . . . . . . . . . 24The Influence of the Child’s Feeding and

Oral Motor Skills . . . . . . . . . . . . . . . . . . . . . . . 25The Influence of the Child’s Emotional State

and Temperament . . . . . . . . . . . . . . . . . . . . . . 25The Influence of the Parent’s Emotional State

and Temperament . . . . . . . . . . . . . . . . . . . . . . 27

Observing and Understanding the Mealtime Environment . . . . . . . . . . . . . . . . . . . . . . . 28

Chapter 3 Mealtime Roles . . . . . . . . . . . . . . . . 31

The Mealtime Dance . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32Birth to 3 Months—Homeostasis

and Mealtimes . . . . . . . . . . . . . . . . . . . . . . . . . . 324 to 7 Months—Socialization at Mealtime . . . . . 33

Parent and Baby Roles During Infancy . . . . 34Emerging Independence . . . . . . . . . . . . . . . . . . . 36

Parent and Baby Roles Between 6 and 12 Months . . . . . . . . . . . . . . . . . . . . 36

The Independent Toddler . . . . . . . . . . . . . . . . . . . 38Parent Roles That Encourage Toddlers

to Eat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39The Older Child . . . . . . . . . . . . . . . . . . . . . . . . . . . 41Special Feeding Issues . . . . . . . . . . . . . . . . . . . . . 41

Chapter 4 Anatomy and Physiology of Eating . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Oral and Pharyngeal Structures . . . . . . . . . . . . . . . . . . 43

Esophageal and Gastrointestinal Tract Structures . . . . 45

Form and Function—Cavities, Tubes, and Valves . . . . 46

Neural Control in Eating . . . . . . . . . . . . . . . . . . . . . . . . 47The Cranial Nerves . . . . . . . . . . . . . . . . . . . . . . . . 47

Swallowing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49The Process of Swallowing . . . . . . . . . . . . . . . . . . 49

Sequence of Adult Swallowing . . . . . . . . . . . 50Comparison of Infant and Adult Anatomy

for Swallowing . . . . . . . . . . . . . . . . . . . . . . . . . 50Anatomical Differences Between the Newborn

and the Adult Mouth and Pharynx . . . . . . . . . 52Infant Anatomical Maturation and Function . . . 52

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From Pre-Feeding Skills: A Comprehensive Resource for Mealtime Development, 2nd Ed., by S. E. Morris and M. D. Klein, 2000, Austin, TX: PRO-ED. Copyright 2000 by PRO-ED, Inc.

Sucking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53The Process of Sucking . . . . . . . . . . . . . . . . . . . . . 53The Mechanics of Sucking . . . . . . . . . . . . . . . . . . 54

Digestion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54Into the Stomach . . . . . . . . . . . . . . . . . . . . . . . . . 54Into the Intestinal Tract . . . . . . . . . . . . . . . . . . . . 55

The Respiratory and Cardiac Systems . . . . . . . . . . . . . . 56

Chapter 5 Normal Development of Feeding Skills . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

The Influence of Normal Movement Development . . . 62Stability and Mobility . . . . . . . . . . . . . . . . . . . . . . 62Separation of Movement . . . . . . . . . . . . . . . . . . . . 63Straight Planes of Movement to Rotation . . . . . . 63Midline Development . . . . . . . . . . . . . . . . . . . . . . 64Reversion to Earlier Patterns of Movement . . . . 65Sensory Input in the Direction and Selection

of Movement . . . . . . . . . . . . . . . . . . . . . . . . . . . 65Economy and Efficiency of Movement . . . . . . . . 66Rhythmicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66Cultural Influences . . . . . . . . . . . . . . . . . . . . . . . . 67Theme and Variations . . . . . . . . . . . . . . . . . . . . . . 68

The Influence of Oral Sensory Development . . . . . . . . 69Sensory Windows . . . . . . . . . . . . . . . . . . . . . . . . . 69Taste . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

The Influence of Non-Feeding Oral Motor Development . . . . . . . . . . . . . . . . . . . . . . 70

Mouthing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70Non-Nutritive Sucking . . . . . . . . . . . . . . . . . . . . . 71

A Sequential Look at Feeding Skills . . . . . . . . . . . . . . . 72Feeding Positions . . . . . . . . . . . . . . . . . . . . . . . . . 73Food Quantity . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74Food Types and the Transition

From Liquids to Table Foods . . . . . . . . . . . . . . 74Newborn Oral Motor Reflexes . . . . . . . . . . . . . . . 75Sucking Liquids From the Bottle or Breast . . . . 76Sucking Liquids From a Cup . . . . . . . . . . . . . . . . 79Sucking Liquids From a Straw . . . . . . . . . . . . . . 80Sucking Soft Solid Foods From the Spoon . . . . . 81Swallowing Liquids . . . . . . . . . . . . . . . . . . . . . . . . 82Swallowing Semisolids . . . . . . . . . . . . . . . . . . . . . 83Swallowing Solids . . . . . . . . . . . . . . . . . . . . . . . . . 84Coordination of Sucking, Swallowing,

and Breathing . . . . . . . . . . . . . . . . . . . . . . . . . . 84Control of Drooling . . . . . . . . . . . . . . . . . . . . . . . . 85

Jaw Movements in Biting . . . . . . . . . . . . . . . . . . 85Jaw Movements in Chewing . . . . . . . . . . . . . . . . 86Tongue Movements in Chewing . . . . . . . . . . . . . 87Lip Movements in Chewing . . . . . . . . . . . . . . . . 88Chewing Efficiency . . . . . . . . . . . . . . . . . . . . . . . 89

A Global Look at Feeding Skills . . . . . . . . . . . . . . . . . . 89Newborns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 893-Month-Old Infants . . . . . . . . . . . . . . . . . . . . . . 906-Month-Old Infants . . . . . . . . . . . . . . . . . . . . . . 909-Month-Old-Infants . . . . . . . . . . . . . . . . . . . . . . 9112-Month-Old Children . . . . . . . . . . . . . . . . . . . 9215-Month-Old Children . . . . . . . . . . . . . . . . . . . 9218-Month-Old Children . . . . . . . . . . . . . . . . . . . 932-Year-Old Children . . . . . . . . . . . . . . . . . . . . . . 93Older Children . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

Developmental Perspectives . . . . . . . . . . . . . . . . . . . . . 94

Chapter 6 Factors That Limit Feeding Skill Development . . . . . . . . . . . . . . . 97

Structural Limits . . . . . . . . . . . . . . . . . . . . . . . . 100Types of Structural Limitations and

Their Influence on Feeding . . . . . . . . . . 100Structural Limitations Through

the Feeding System . . . . . . . . . . . . . . . . 100Physiological Limits . . . . . . . . . . . . . . . . . . . . . . 105

Types of Physiological Limitations and Their Influence on Feeding . . . . . . . . . . 105

Physiological Limitations Through the Feeding System . . . . . . . . . . . . . . . . 106

Wellness Limits . . . . . . . . . . . . . . . . . . . . . . . . . . 111Types of Wellness Limitations and

Their Influence on Feeding . . . . . . . . . . 111Wellness Limitations Through

the Feeding System . . . . . . . . . . . . . . . . 112Experiential Limits . . . . . . . . . . . . . . . . . . . . . . . 113

Types of Experiential Limitations and TheirInfluence on Feeding and Mealtime . . . 113

Experiential Limitations Through the Feeding and Mealtime System . . . . . . . . 113

Environmental Limits . . . . . . . . . . . . . . . . . . . . 118Types of Environmental Limitations and

Their Influence on the Family at Mealtime . . . . . . . . . . . . . . . . . . . . . . . 118

Environmental Limitations Through the Feeding and Mealtime System . . . . 119

Relating to Factors That Limit Feeding SkillDevelopment . . . . . . . . . . . . . . . . . . . . . . . . . . 119

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Chapter 7 Factors That Limit Oral Motor Skills . . . . . . . . . . . . . . . . . . . . . . . . . . 121

The Terminology of Tone and Movement . . . . . . . . . . 122Muscle Tension . . . . . . . . . . . . . . . . . . . . . . . . . . 122

Low Tone . . . . . . . . . . . . . . . . . . . . . . . . . . . 122High Tone . . . . . . . . . . . . . . . . . . . . . . . . . . . 122Fluctuating Tone . . . . . . . . . . . . . . . . . . . . . 123

Direction of Movement . . . . . . . . . . . . . . . . . . . . 123Extension . . . . . . . . . . . . . . . . . . . . . . . . . . . 123Flexion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123Retraction . . . . . . . . . . . . . . . . . . . . . . . . . . . 123Protraction and Protrusion . . . . . . . . . . . . . 123Exaggerated . . . . . . . . . . . . . . . . . . . . . . . . . 123

Timing and Intensity of Movement . . . . . . . . . . 124Thrust . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124

Distribution of Movement . . . . . . . . . . . . . . . . . 124Symmetrical . . . . . . . . . . . . . . . . . . . . . . . . . 124Asymmetrical . . . . . . . . . . . . . . . . . . . . . . . . 124

Problems With Function of Individual Oral Structures . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124

Jaw . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125Tongue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126Lips and Cheeks . . . . . . . . . . . . . . . . . . . . . . . . . 127Palate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128

Problems With Motor Processes . . . . . . . . . . . . . . . . . 129

Problems With Sensory Processes . . . . . . . . . . . . . . . . 130Hyperreaction . . . . . . . . . . . . . . . . . . . . . . . . . . . 131Hyporeaction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132Sensory Defensiveness . . . . . . . . . . . . . . . . . . . . 132Sensory Overload . . . . . . . . . . . . . . . . . . . . . . . . 133

Problems With Feeding Processes . . . . . . . . . . . . . . . . 133Sucking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133Swallowing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134Biting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135Chewing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135Oral Motor Limitations Glossary . . . . . . . . . . . . 136

Limiting Oral Motor Patterns . . . . . . . . . . . 136Limiting Jaw Patterns . . . . . . . . . . . . . . . . . 136Limiting Tongue Patterns . . . . . . . . . . . . . . 136Limiting Lip Patterns . . . . . . . . . . . . . . . . . 137Limiting Sensory Factors . . . . . . . . . . . . . . 137

Chapter 8 Supportive Diagnostic Tests . . . . . . . . . . . . . . . . . . . . . . . . . . 139

Evaluation of Swallowing Function . . . . . . . . . . . . . . 139Videofluoroscopic Swallow Study . . . . . . . . . . . 139

When to Refer? . . . . . . . . . . . . . . . . . . . . . . . 140Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . 140Limitations in Performing a VFSS . . . . . . . 140Invaluable Information the VFSS

Can Tell Us . . . . . . . . . . . . . . . . . . . . . . . . 141What a VFSS Cannot Tell Us . . . . . . . . . . . . 143Questions to Consider Before a VFSS . . . . 143What to Do With the Results of a VFSS? . . 145

Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . 145Advantages of Ultrasound . . . . . . . . . . . . . . 145Limitations of Ultrasound . . . . . . . . . . . . . . 146

Fiberoptic Endoscopic Evaluation of Swallowing(FEES) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146

Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . 146Advantages of FEES . . . . . . . . . . . . . . . . . . . 146Limitations of FEES . . . . . . . . . . . . . . . . . . 147

Cervical Auscultation . . . . . . . . . . . . . . . . . . . . . 147Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . 147Advantages of Cervical Auscultation . . . . . 147Limitations of Cervical Auscultation . . . . . 147

Evaluation of Gastrointestinal Function . . . . . . . . . . . 147Upper GI Series . . . . . . . . . . . . . . . . . . . . . . . . . . 147

Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . 148Advantages of the UGI Series . . . . . . . . . . . 148Limitations of the UGI Series . . . . . . . . . . . 148Implications for the Feeding Therapist . . . 149

pH Probe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . 151Advantages of the pH Probe . . . . . . . . . . . . 151Limitations of the pH Probe . . . . . . . . . . . . 151Keeping it in Perspective . . . . . . . . . . . . . . . 152

Upper Gastrointestinal Endoscopy . . . . . . . . . . 152Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . 152

Gastroesophageal Scintigraphy . . . . . . . . . . . . . 153Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . 153Advantages of Scintigraphy . . . . . . . . . . . . . 153Limitations of Scintigraphy . . . . . . . . . . . . 154

Esophageal Manometry . . . . . . . . . . . . . . . . . . . 154

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Evaluation of Respiratory Function . . . . . . . . . . . . . . 154Bronchoscopy With Bronchoalveolar Lavage . . 154

Chapter 9 Mealtime Assessment . . . . . . . . 157

Foundations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157The Elements of the Story . . . . . . . . . . . . . . . . . 157Seeking the Answers . . . . . . . . . . . . . . . . . . . . . . 158

The Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159Rational and Intuitive Approaches . . . . . . . . . . . 159Global Overview . . . . . . . . . . . . . . . . . . . . . . . . . 160Sequential Analysis . . . . . . . . . . . . . . . . . . . . . . . 160Specific Applications to the Feeding

Assessment: Jason . . . . . . . . . . . . . . . . . . . . . 160

Approaches to Gathering Information . . . . . . . . . . . . 163Interview and Parent Questionnaire . . . . . . . . . 163Observation of the Child . . . . . . . . . . . . . . . . . . . 163

Observation Settings . . . . . . . . . . . . . . . . . . 163Parent-Child Feeding Interaction . . . . . . . 163Therapist’s Observations From

Feeding the Child . . . . . . . . . . . . . . . . . . 164Recording Mealtime Assessment Data . . . . . . . 164

Parent Concerns . . . . . . . . . . . . . . . . . . . . . 164Other Concerns . . . . . . . . . . . . . . . . . . . . . . 164Diagnoses and Medical History . . . . . . . . . . 165Previous Therapies and Assessments . . . . . 165Current Therapies and School . . . . . . . . . . 165Feeding History . . . . . . . . . . . . . . . . . . . . . . 165Current Medications . . . . . . . . . . . . . . . . . . 165Growth Parameters . . . . . . . . . . . . . . . . . . . 166Mealtime Routine . . . . . . . . . . . . . . . . . . . . 166Child’s Developmental Skills . . . . . . . . . . . 166Mealtime Relationship and Interactions . . 166Mealtime Communication Skills

(Strengths and Challenges) . . . . . . . . . . 166Mealtime Physical Skills

(Strengths and Challenges) . . . . . . . . . . 166Mealtime Sensory Skills

(Strengths and Challenges) . . . . . . . . . . 167Mealtime Oral Motor Skills

(Strengths and Challenges) . . . . . . . . . . 167Treatment Explorations . . . . . . . . . . . . . . . . 167Ongoing Questions . . . . . . . . . . . . . . . . . . . 167Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . 167Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168

Developing a Feeding Plan With the Parent . . . 168Respect Parent Learning Styles . . . . . . . . . 168

Exploring the Initial Feeding Plan . . . . . . . . . . . 169Demonstrate the Feeding Plan . . . . . . . . . . 169Establishing a Follow-Up Plan . . . . . . . . . . 170

Creating the Report . . . . . . . . . . . . . . . . . . . . . . . . . . . 170Who and What? . . . . . . . . . . . . . . . . . . . . . . . . . . 170How? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171

Links Between Assessment and Treatment . . . . . . . . . 172The Feeding Team . . . . . . . . . . . . . . . . . . . . . . . . 172The Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174

Parent Mealtimes Questionnaire—Eating and Drinking Skills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175

Parent Mealtimes Questionnaire—Tube Feedings and Beginning Oral Feedings . . . . . . . . . . . . . . . . . . 179

Mealtime Assessment Guide . . . . . . . . . . . . . . . . . . . . . 184

Chapter 10 The Bridge to Treatment: Setting Priorities and Problem Solving . . . 187

Organizing Information . . . . . . . . . . . . . . . . . . . . . . . . 187Major Feeding Clusters . . . . . . . . . . . . . . . . . . . . 188

Motor-Based Feeding Problems . . . . . . . . . 188Sensory-Based Feeding Problems . . . . . . . 189Structurally Based Feeding Problems . . . . 190Experientially Based Feeding Problems . . . 191Combination Feeding Problems . . . . . . . . . 192

What Works? What Doesn’t Work? . . . . . . . . . . 193Pattern Clusters . . . . . . . . . . . . . . . . . . . . . . . . . 196

Describing the Patterns . . . . . . . . . . . . . . . . 197Creating the Plan . . . . . . . . . . . . . . . . . . . . . 197

Setting Priorities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199Identifying the Key Issues . . . . . . . . . . . . . . . . . 199

Problem Solving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205The Big Picture Model . . . . . . . . . . . . . . . . . . . . 205The Component Skills Model . . . . . . . . . . . . . . . 208

Identifying the Target Components . . . . . . 209Observation and Charting of

Component Skills . . . . . . . . . . . . . . . . . . 210Moving Toward Efficient Oral Feeding—

Guidelines for Therapy . . . . . . . . . . . . . . 211

Building Bridges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213

What’s Working and What’s Not Working? . . . . . . . . . 214

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Chapter 11 Creating the Mealtime Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215

Setting Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215Dylan, Age 12 Months . . . . . . . . . . . . . . . . . . . . . 216

Long-Term Behavioral Goal 1 . . . . . . . . . . . 217Treatment Strategies . . . . . . . . . . . . . . . . . . 217Long-Term Behavioral Goal 2 . . . . . . . . . . . 217Treatment Strategies . . . . . . . . . . . . . . . . . . 218Long-Term Behavioral Goal 3 . . . . . . . . . . . 218Treatment Strategies . . . . . . . . . . . . . . . . . . 218

Tyrone, Age 5 Years . . . . . . . . . . . . . . . . . . . . . . . 219Oral Motor Support for Feeding . . . . . . . . . 219

Implementing the Plan . . . . . . . . . . . . . . . . . . . . . . . . 219Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220

Frequency . . . . . . . . . . . . . . . . . . . . . . . . . . . 220Type . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221

Content . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222

Mealtime Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224Part 1: Positive Mealtimes . . . . . . . . . . . . . . . . . . 224Part 2: Oral Awareness and Discrimination . . . . 225Part 3: Rhythmical Suck-Swallow-Breathe . . . . 226

Individual Mealtime Plan . . . . . . . . . . . . . . . . . . . . . . . 227Supporting and Limiting

Mealtime Skills . . . . . . . . . . . . . . . . . . . . . 227Short-Term Mealtime Focus

and Objectives . . . . . . . . . . . . . . . . . . . . . 227Mealtime Suggestions . . . . . . . . . . . . . . . . . 227

Mealtime Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230

Individual Mealtime Plan . . . . . . . . . . . . . . . . . . . . . . . 231

Chapter 12 Treatment Principles and Perspectives . . . . . . . . . . . . . . . . . . . . . . . . . . 235

The Concept of Mealtime Programs . . . . . . . . . . . . . . 235Mealtime Circles of Influence . . . . . . . . . . . . . . 235Feeding Programs, Oral Motor Treatment

Programs, and Mealtime Programs . . . . . . . 239Interplay of Assessment and Treatment . . . 240

Guiding Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241The Dance of Mealtime . . . . . . . . . . . . . . . . . . . . 241Developing Trust and Respect . . . . . . . . . . . . . . 242

Trusting Ourselves and Others . . . . . . . . . . 242Judgments and Acceptance . . . . . . . . . . . . 242Getting the Child’s Permission . . . . . . . . . . 242

Following the Child’s Lead . . . . . . . . . . . . . . . . . 242Observing the Child’s Response . . . . . . . . . 242Inner Wisdom . . . . . . . . . . . . . . . . . . . . . . . 243The Treatment Partnership . . . . . . . . . . . . . 243

Building on the Child’s Assets . . . . . . . . . . . . . . 243

Approaches, Strategies, and Techniques . . . . . . . . . . . 244Approach or Philosophy . . . . . . . . . . . . . . . . . . . 245Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245Alternative Pathways . . . . . . . . . . . . . . . . . . . . . . 246

The What and How of Therapy . . . . . . . . . . . . . . . . . . . 246What We Do . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246How We Do It . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247

Chapter 13 Learning and Communication at Mealtimes . . . . . . . . . . . . 249

Maximizing the Ability to Learn . . . . . . . . . . . . . . . . . 249Principles of Learning . . . . . . . . . . . . . . . . . . . . . 249Making Changes: The Learning

Environment . . . . . . . . . . . . . . . . . . . . . . . . . 251The Power of Beliefs and Expectations . . . . . . . 251The Power of Suggestion . . . . . . . . . . . . . . . . . . 253The Power of Music . . . . . . . . . . . . . . . . . . . . . . . 254The Power of Imagination . . . . . . . . . . . . . . . . . 256Concepts of Change . . . . . . . . . . . . . . . . . . . . . . 257

Mealtime Communication . . . . . . . . . . . . . . . . . . . . . . 260Observation and Discovery . . . . . . . . . . . . . . . . . 260Enhancing the Mealtime Environment . . . . . . 262

Physical Environment . . . . . . . . . . . . . . . . . 262Sensory Environment . . . . . . . . . . . . . . . . . 263Communication Environment . . . . . . . . . . 263

Messages From Within . . . . . . . . . . . . . . . . . . . . 264Hunger and Satiation . . . . . . . . . . . . . . . . . 264Enhancing Inner Messages . . . . . . . . . . . . . 265

Behavior as Communication . . . . . . . . . . . . . . . 266Mealtime Communication Tools . . . . . . . . . . . . 267

Mealtime Communication Board . . . . . . . . 267Mealtime Place Mat . . . . . . . . . . . . . . . . . . . 268Mealtime Book . . . . . . . . . . . . . . . . . . . . . . . 268

The Interplay of Communication and Learning . . . . . 269Messages and Belief Systems . . . . . . . . . . . . . . . 269Behavior and Learning . . . . . . . . . . . . . . . . . . . . 271

Behavior Modification Programs . . . . . . . . 271Changing Children’s Feeding Behavior

Through Behavior Modification . . . . . . . 274

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Incorporating Behavioral Principles of Learning in Mealtime Programs . . . . 275

Learning Alternatives in Teaching Feeding and Mealtime Skills . . . . . . . . . 276

Chapter 14 The Sensory Challenges of Mealtime . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277

The Senses and Mealtimes . . . . . . . . . . . . . . . . . . . . . . 277Personal Nature of the Senses . . . . . . . . . . . . . . 277Beyond the Mouth . . . . . . . . . . . . . . . . . . . . . . . . 277

Understanding Sensory Variables . . . . . . . . . . . . . . . . 278Vestibular Sensory Information

(Balance and Equilibrium) . . . . . . . . . . . 278Proprioceptive Sensory Information

(Inner-Muscle and Joint Awareness) . . . 279Tactile Sensory Information (Touch) . . . . . 281Gustatory Sensory Information (Taste) . . . 281Olfactory Sensory Information (Smell) . . . 282Visual Sensory Information (Sight) . . . . . . 283Auditory Sensory Information (Hearing) . 285

Sensory Preparation and Mealtimes . . . . . . . . . . . . . . 285Listening to the Child . . . . . . . . . . . . . . . . . . . . . 285Sensory Preparation of the Environment . . . . . 286Sensory Preparation of the Child . . . . . . . . . . . . 286Sensory Preparation for the Adult . . . . . . . . . . . 287Sensory Variables During the Meal . . . . . . . . . . 287

Grading of the Sensory Continuum of Food . . . . . . . . . . . . . . . . . . . . . . . . . . . 287

Sensory Preparation for Transition to the Next Activity . . . . . . . . . . . . . . . . . . . . . 288

Helping Children Handle the New Sensory Challenges of Mealtimes . . . . . . . . . . . . . . . . 288

Listen to Children . . . . . . . . . . . . . . . . . . . . 288Prepare for the Meal . . . . . . . . . . . . . . . . . . 289Preferences are Personal . . . . . . . . . . . . . . . 289Seek Foods Most Likely to Elicit

Favorable Responses . . . . . . . . . . . . . . . . 289Get Permission . . . . . . . . . . . . . . . . . . . . . . . 289Start With the Familiar . . . . . . . . . . . . . . . . 289One Thing at a Time . . . . . . . . . . . . . . . . . . 289Mouthing Helps . . . . . . . . . . . . . . . . . . . . . . 290Be Aware of Sensory Surprises . . . . . . . . . . 290

Environmental Sensory Variable Analysis . . . . . . . . . 291

Chapter 15 Positioning and HandlingInfluences on the Mealtime . . . . . . . . . . . . . . . 293

Handling and Movement . . . . . . . . . . . . . . . . . . . . . . . 293

Considerations for Positioning at Mealtimes . . . . . . . 293Mealtime Communication . . . . . . . . . . . . . . . . . 294Mealtime Socialization . . . . . . . . . . . . . . . . . . . . 295Developmental Feeding Skills . . . . . . . . . . . . . . 295Feeding Methods . . . . . . . . . . . . . . . . . . . . . . . . . 296Oral Motor Skills . . . . . . . . . . . . . . . . . . . . . . . . . 296Gastrointestinal, Oral-Facial, Respiratory,

and Neurological Positioning Needs . . . . . . . 296

Physical Needs and Seating Choices . . . . . . . . . . . . . . 297The Child’s Individual Needs . . . . . . . . . . . . . . . 297

Observing Body Alignment . . . . . . . . . . . . . . . . . . . . . 298How Do All of These Components Interact? . . . 298

Hips and Pelvis . . . . . . . . . . . . . . . . . . . . . . . 298Sitting Base . . . . . . . . . . . . . . . . . . . . . . . . . 298Feet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299Trunk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299Shoulder Girdle . . . . . . . . . . . . . . . . . . . . . . 299Relationship of the Head and Spine . . . . . . 300Abdominal-Pelvic Girdle . . . . . . . . . . . . . . . 300Freedom of Movement . . . . . . . . . . . . . . . . 300Vision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301Compensating Patterns of Movement . . . . 301

Recording Information . . . . . . . . . . . . . . . . . . . . 302Comfort . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 302Straps and Belts . . . . . . . . . . . . . . . . . . . . . . . . . . 302Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 302Feeder’s Position . . . . . . . . . . . . . . . . . . . . . . . . . 302Recording Information . . . . . . . . . . . . . . . . . . . . 303

Active Therapy, Positioning for Meals and Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 304

Helping Children Handle the Physical Challenges of Mealtimes . . . . . . . . . . . . . . . . 304

Listen to Children . . . . . . . . . . . . . . . . . . . . 304Prepare for the Meal . . . . . . . . . . . . . . . . . . 304Direct Treatment at Primary Patterns,

Not Compensatory Patterns . . . . . . . . . . 304Help Children and Adults Develop

Body Awareness . . . . . . . . . . . . . . . . . . . . 305There is Always More Than One Way . . . . . 305Introduce Very Small Changes . . . . . . . . . . 305Start at the Bottom . . . . . . . . . . . . . . . . . . . 305Children Learn to Move by Moving . . . . . . 305

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Help Children Work With Their Special Chairs . . . . . . . . . . . . . . . . . . . . . 305

Identify a Series of Seating Options That Fit the Child . . . . . . . . . . . . . . . . . . 306

Position at Mealtime Addresses the Child’sPhysical and Emotional Needs . . . . . . . . 306

Seating and Positioning Considerationsfor Mealtime Support . . . . . . . . . . . . . . . . . . . . . . . . 307

Body Alignment for Seating and PositioningChecklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309

Chapter 16 Issues of Nutrition . . . . . . . . . . . 311

Assessment of Nutrition . . . . . . . . . . . . . . . . . . . . . . . . 312History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312Dietary Records . . . . . . . . . . . . . . . . . . . . . . . . . . 312Anthropometric Measures . . . . . . . . . . . . . . . . . 313

Intake . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313Feeding Skills . . . . . . . . . . . . . . . . . . . . . . . . . . . 313Food . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314

Calories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315Macronutrients . . . . . . . . . . . . . . . . . . . . . . 315Micronutrients . . . . . . . . . . . . . . . . . . . . . . . 317Beyond Vitamins and Minerals . . . . . . . . . . 320Dietary Diversity . . . . . . . . . . . . . . . . . . . . . 321Developmental Guidelines . . . . . . . . . . . . . 323

Helping Children Improve Dietary Intake . . . . 324

Utilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 326Digestion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 326

Enzymes and the Breakdown of Food . . . . 326Water and Digestion . . . . . . . . . . . . . . . . . . 327Stress and Digestion . . . . . . . . . . . . . . . . . . 328Bioavailability of Nutrients . . . . . . . . . . . . . 329

Metabolism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329Helping Children Utilize the Foods They Eat . . 330

Output . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331Input is Defined by the Output Required . . . . . 331Helping Children Balance Intake

With Energy Output . . . . . . . . . . . . . . . . . . . 332

Meeting the Child’s Nutritional Needs . . . . . . . . . . . . 333Increasing Calories . . . . . . . . . . . . . . . . . . . . . . . 333

Protein Calories . . . . . . . . . . . . . . . . . . . . . . 333Fat Calories . . . . . . . . . . . . . . . . . . . . . . . . . 334Caloric Values of Specific High

Nutritional Foods . . . . . . . . . . . . . . . . . . 335Increasing Dietary Diversity . . . . . . . . . . . . . . . . 336

Tube Feedings . . . . . . . . . . . . . . . . . . . . . . . 337

Increasing Nutrients . . . . . . . . . . . . . . . . . . . . . . 338Food Supplements . . . . . . . . . . . . . . . . . . . . 338Choices at the Supermarket and

in Therapy . . . . . . . . . . . . . . . . . . . . . . . . 339Special Health Needs and Nutrition . . . . . . . . . 341

Medications . . . . . . . . . . . . . . . . . . . . . . . . . 341Allergies and Food Sensitivities . . . . . . . . . 343Dietary Aspects of Attention Deficit

and Learning Disabilities . . . . . . . . . . . . 346Gastroesophageal Reflux . . . . . . . . . . . . . . . 347Mucous Congestion . . . . . . . . . . . . . . . . . . . 347Constipation . . . . . . . . . . . . . . . . . . . . . . . . . 348Diet and Dental Health . . . . . . . . . . . . . . . . 349Children on Special Diets . . . . . . . . . . . . . . 350

Maximizing Nutrition for Children With Special Health Needs . . . . . . . . . . . . . . 350

Chapter 17 Specifics of Oral Motor Treatment . . . . . . . . . . . . . . . . . . . . . 353

Oral Motor Problems and Treatment Directions . . 356

Problems With Function of Individual Oral Structures . . . . . . . . . . . . . . . . . . . . . . . . . . . . 356

Jaw . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 356Jaw Thrust . . . . . . . . . . . . . . . . . . . . . . . . . . . 356Exaggerated Jaw Excursions . . . . . . . . . . . . 357Jaw Instability . . . . . . . . . . . . . . . . . . . . . . . . 359Jaw Clenching . . . . . . . . . . . . . . . . . . . . . . . . 360Tooth Grinding . . . . . . . . . . . . . . . . . . . . . . . 361Stability Bite . . . . . . . . . . . . . . . . . . . . . . . . . 362Tonic Bite . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363Jaw Retraction . . . . . . . . . . . . . . . . . . . . . . . . 365

Tongue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 366Tongue Retraction . . . . . . . . . . . . . . . . . . . . 366Exaggerated Tongue Protrusion . . . . . . . . . 367Tongue Thrust . . . . . . . . . . . . . . . . . . . . . . . . 368Low Tone With Unusual

Tongue Configuration . . . . . . . . . . . . . . . 370Tongue Asymmetry . . . . . . . . . . . . . . . . . . . . 371Limited Tongue Movement . . . . . . . . . . . . . 371

Lips and Cheeks . . . . . . . . . . . . . . . . . . . . . . . . . . 372Lip Retraction and Pursing . . . . . . . . . . . . . 372Low Tone in the Cheeks . . . . . . . . . . . . . . . . 373Limited Upper Lip Movement . . . . . . . . . . . 375

Palate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 376Nasal Reflux . . . . . . . . . . . . . . . . . . . . . . . . . . 376Structural Deformities of the Mouth . . . . . 376

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Problems With Sensory Processes . . . . . . . . . . . . . . . . 377Hyposensitivity . . . . . . . . . . . . . . . . . . . . . . . . . . 377

Hyporeaction . . . . . . . . . . . . . . . . . . . . . . . . . 377Hypersensitivity . . . . . . . . . . . . . . . . . . . . . . . . . . 379

Hyperreaction . . . . . . . . . . . . . . . . . . . . . . . . 379Sensory Defensiveness . . . . . . . . . . . . . . . . . 380Sensory Overload . . . . . . . . . . . . . . . . . . . . . 381

Problems With Feeding Processes . . . . . . . . . . . . . . . . 383Sucking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383

Facilitating a Normal Suckling Pattern . . . 383Facilitating the Transition From Suckling

to Sucking . . . . . . . . . . . . . . . . . . . . . . . . 384Facilitating Mature Oral Movements

During Spoon Feeding of Soft Foods . . . 385Facilitating Mature Oral Movements

During Cup Drinking . . . . . . . . . . . . . . . 386Swallowing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 387

Facilitating a Normal Swallowing Pattern:Aspiration . . . . . . . . . . . . . . . . . . . . . . . . . 387

Facilitating a Normal Swallowing Pattern:Gagging . . . . . . . . . . . . . . . . . . . . . . . . . . . 389

Facilitating a Normal Swallowing Pattern:Drooling . . . . . . . . . . . . . . . . . . . . . . . . . . 390

Facilitating a Mature Swallowing Pattern . . . . . . . . . . . . . . . . . . . . . . . . . . . 391

Coordination of Sucking, Swallowing, and Breathing: Breast-Feeding or Bottle-Feeding . . . . . . . . . . . . . . . . . . . . . 392

Coordination of Sucking, Swallowing, and Breathing: Cup Drinking . . . . . . . . . 393

Biting and Chewing . . . . . . . . . . . . . . . . . . . . . . 394Facilitation of a Normal Controlled

Biting Pattern . . . . . . . . . . . . . . . . . . . . . . 394Facilitation of Munching, the Earliest

Stage of Chewing . . . . . . . . . . . . . . . . . . . 395Facilitation of Lateralization in Chewing . . 396

The Role of Food in Therapy . . . . . . . . . . . . . . . . . . . . 398Food Transitions . . . . . . . . . . . . . . . . . . . . . . . . . 398

Moving From Liquids to Smooth Solids . . . 398Moving From Smooth Solids

to Lumpy Solids . . . . . . . . . . . . . . . . . . . . 399Moving From Lumpy Solids

to Chewy Solids . . . . . . . . . . . . . . . . . . . . 400

Treatment Strategies and Activities . . . . . . . . . . . . . 402

Physical Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 402

Supporting Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . 402Postural Alignment . . . . . . . . . . . . . . . . . . . . . . . 402

Head, Neck, and Trunk Alignment . . . . . . . 402Capital Flexion . . . . . . . . . . . . . . . . . . . . . . . 403Symmetry . . . . . . . . . . . . . . . . . . . . . . . . . . . 403

Stability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 404Head and Trunk Stability . . . . . . . . . . . . . . . 404Airway Stability . . . . . . . . . . . . . . . . . . . . . . . 405

Limiting Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 406Change Tone . . . . . . . . . . . . . . . . . . . . . . . . . . . . 406

Decrease Tone . . . . . . . . . . . . . . . . . . . . . . . . 406Increase Tone . . . . . . . . . . . . . . . . . . . . . . . . 406Stabilize Tone . . . . . . . . . . . . . . . . . . . . . . . . 407

Change Physical Position . . . . . . . . . . . . . . . . . . 407Influence Tone . . . . . . . . . . . . . . . . . . . . . . . 407Change or Break Up a Total Pattern . . . . . . 407Influence Interaction . . . . . . . . . . . . . . . . . . 408Influence Digestion . . . . . . . . . . . . . . . . . . . 408

Change Sensory Input . . . . . . . . . . . . . . . . . . . . 409Decrease Input . . . . . . . . . . . . . . . . . . . . . . . 409Increase Input . . . . . . . . . . . . . . . . . . . . . . . . 409Increase Sensorimotor Awareness . . . . . . . . 409

Change Emotional Input and Response . . . . . . 410Interaction . . . . . . . . . . . . . . . . . . . . . . . . . . . 410Learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . 410

Sensory Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411

Supporting Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411Sensory Awareness . . . . . . . . . . . . . . . . . . . . . . . 411

Overall Sensory System . . . . . . . . . . . . . . . . 411Face and Mouth . . . . . . . . . . . . . . . . . . . . . . 411

Sensory Modulation . . . . . . . . . . . . . . . . . . . . . . 413Overall Sensory System . . . . . . . . . . . . . . . . 413Face and Mouth . . . . . . . . . . . . . . . . . . . . . . 414

Sensory Discrimination . . . . . . . . . . . . . . . . . . . 414Overall Sensory System . . . . . . . . . . . . . . . . 414Face and Mouth . . . . . . . . . . . . . . . . . . . . . . 414

Sensory Feedback . . . . . . . . . . . . . . . . . . . . . . . . 415Overall Sensory System . . . . . . . . . . . . . . . . 415Face and Mouth . . . . . . . . . . . . . . . . . . . . . . 415

Limiting Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 417Hyporeaction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 417

Environmental Sensory Input . . . . . . . . . . . 417Bodily Sensory Input . . . . . . . . . . . . . . . . . . 417

Hyperreaction . . . . . . . . . . . . . . . . . . . . . . . . . . . 418Environmental Sensory Input . . . . . . . . . . . 418Bodily Sensory Input . . . . . . . . . . . . . . . . . . 419

Sensory Overload . . . . . . . . . . . . . . . . . . . . . . . . 421

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Mealtime Input . . . . . . . . . . . . . . . . . . . . . . . 421Food Input . . . . . . . . . . . . . . . . . . . . . . . . . . . 421Sensory Defensiveness . . . . . . . . . . . . . . . . . 422

Interaction Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 423

Supporting Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . 423Trust . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 423Anticipation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 424Communication . . . . . . . . . . . . . . . . . . . . . . . . . 424

Limiting Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 425Physical and Sensory . . . . . . . . . . . . . . . . . . . . . 425Negative Interactions . . . . . . . . . . . . . . . . . . . . . 425Reduced Independence . . . . . . . . . . . . . . . . . . . . 429Lack of Opportunity . . . . . . . . . . . . . . . . . . . . . . 430

Oral Control Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . 430

Supporting Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . 430Jaw Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 430

Jaw Opening and Closing . . . . . . . . . . . . . . . 430Jaw Stability in an Open Position . . . . . . . . 431Jaw Stability in a Closed Position . . . . . . . . 432Graded Jaw Movements . . . . . . . . . . . . . . . . 432

Lip and Cheek Control . . . . . . . . . . . . . . . . . . . . 434Lip Rounding and Spreading . . . . . . . . . . . . 434Lip Closure . . . . . . . . . . . . . . . . . . . . . . . . . . 435Cheek Compression . . . . . . . . . . . . . . . . . . . 435

Tongue Control . . . . . . . . . . . . . . . . . . . . . . . . . . 435Tongue Shape . . . . . . . . . . . . . . . . . . . . . . . . 435Tongue Movement . . . . . . . . . . . . . . . . . . . . 436

Velopharyngeal Control . . . . . . . . . . . . . . . . . . . 438Palatal Closure . . . . . . . . . . . . . . . . . . . . . . . 438Timing and Coordination . . . . . . . . . . . . . . . 438

Oral Motor Imitation . . . . . . . . . . . . . . . . . . . . . 439Oral-Facial Imitation . . . . . . . . . . . . . . . . . . 439

Combined Oral Sensorimotor Control . . . . . . . 439Toothbrushing . . . . . . . . . . . . . . . . . . . . . . . 439Mouthing . . . . . . . . . . . . . . . . . . . . . . . . . . . . 441Oral Exploration . . . . . . . . . . . . . . . . . . . . . . 442

Limiting Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 443Increased Tone . . . . . . . . . . . . . . . . . . . . . . . . . . 443

Face . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 443Jaw . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 443Tongue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 443Lips and Cheeks . . . . . . . . . . . . . . . . . . . . . . 443

Decreased Tone . . . . . . . . . . . . . . . . . . . . . . . . . . 444Face . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 444Jaw . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 444

Tongue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 445Lips and Cheeks . . . . . . . . . . . . . . . . . . . . . . 445

Clenching and Biting . . . . . . . . . . . . . . . . . . . . . 446Jaw Clenching . . . . . . . . . . . . . . . . . . . . . . . . 446Tonic Bite Reflex . . . . . . . . . . . . . . . . . . . . . . 447Stability Bite . . . . . . . . . . . . . . . . . . . . . . . . . 449Tooth Grinding . . . . . . . . . . . . . . . . . . . . . . . 450

Thrusting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 451Jaw . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 451Tongue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 451

Exaggerated Movement . . . . . . . . . . . . . . . . . . . 452Jaw (Wide Excursions) . . . . . . . . . . . . . . . . . 452Tongue (Protrusion) . . . . . . . . . . . . . . . . . . . 453

Retraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 455Jaw . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 455Tongue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 455Lips and Cheeks . . . . . . . . . . . . . . . . . . . . . . 456

Asymmetry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 457Tongue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 457

Limited Movement . . . . . . . . . . . . . . . . . . . . . . . 458Jaw . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 458Tongue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 458Lips and Cheeks . . . . . . . . . . . . . . . . . . . . . . 459

Specific Feeding Skill Issues . . . . . . . . . . . . . . . . . . . . 460

Supporting Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . 460Sucking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 460

Suckle Pattern . . . . . . . . . . . . . . . . . . . . . . . . 460Transition From Suckling to Sucking . . . . 462Spoon Feeding . . . . . . . . . . . . . . . . . . . . . . . 463Cup Drinking . . . . . . . . . . . . . . . . . . . . . . . . 466Straw Drinking . . . . . . . . . . . . . . . . . . . . . . . 467

Swallowing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 469Safe and Efficient Suckle-Swallow . . . . . . . 469Mature Swallow . . . . . . . . . . . . . . . . . . . . . . . 471Saliva Control—Drooling . . . . . . . . . . . . . . 472

Coordination of Sucking, Swallowing, and Breathing . . . . . . . . . . . . . . . . . . . . . . . . . 473

Bottle-Feeding or Breast-Feeding . . . . . . . . 474Cup Drinking . . . . . . . . . . . . . . . . . . . . . . . . 474

Biting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 475Controlled Bite . . . . . . . . . . . . . . . . . . . . . . . 476

Chewing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 477Munching . . . . . . . . . . . . . . . . . . . . . . . . . . . 477Lateralization . . . . . . . . . . . . . . . . . . . . . . . . 478Timing and Coordination . . . . . . . . . . . . . . . 481

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Food Transitions . . . . . . . . . . . . . . . . . . . . . . . . . 481Sensory Transitions . . . . . . . . . . . . . . . . . . . 481Liquids to Smooth Solids . . . . . . . . . . . . . . . 483Smooth Solids to Lumpy Solids . . . . . . . . . 484Lumpy Solids to Chewy Solids . . . . . . . . . . 485

Food Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . 486Food and Oral Movement . . . . . . . . . . . . . . . 486Facilitating Normal Oral Movement . . . . . . 486Limiting Normal Oral Movement . . . . . . . . 489

Limiting Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 490Aspiration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 490Gagging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 490Gastroesophageal Reflux . . . . . . . . . . . . . . . . . . 493Retching . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 493Mouth Stuffing . . . . . . . . . . . . . . . . . . . . . . . . . . 493

Chapter 18 Feeding Materials for Assessment and Treatment . . . . . . . . . . . 495

Choosing Feeding Materials . . . . . . . . . . . . . . . . . . . . . 495Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 495Availability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 496

Selection Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 497Choosing an Appropriate Pacifier . . . . . . . . . . . 497

Guidelines for Use of a Pacifier . . . . . . . . . . 497Criteria for an Effective Pacifier . . . . . . . . . 497

Choosing an Appropriate Nipple . . . . . . . . . . . . 498Guidelines for Use of a Nipple . . . . . . . . . . . 498Criteria for an Effective Nipple . . . . . . . . . . 498

Choosing an Appropriate Bottle . . . . . . . . . . . . . 498Guidelines for Use of a Bottle . . . . . . . . . . . . 498Criteria for an Effective Bottle . . . . . . . . . . . 499

Choosing an Appropriate Cup . . . . . . . . . . . . . . 499Guidelines for Use of a Cup . . . . . . . . . . . . . 499Criteria for an Effective Cup . . . . . . . . . . . . 499

Choosing an Appropriate Straw . . . . . . . . . . . . . 500Guidelines for Use of a Straw . . . . . . . . . . . . 500Criteria for an Effective Straw . . . . . . . . . . . 500

Choosing an Appropriate Spoon . . . . . . . . . . . . 501Guidelines for Use of a Spoon . . . . . . . . . . . 501Criteria for an Effective Spoon . . . . . . . . . . 501

Choosing Appropriate Oral-Facial Stimulation Materials . . . . . . . . . . . . . . . . . . 501

Guidelines for the Use of Oral-FacialStimulation Materials . . . . . . . . . . . . . . . 501

Criteria for Effective Oral-Facial Stimulation Materials . . . . . . . . . . . . . . . 502

Resources for Feeding Materials . . . . . . . . . . . . . . . . . 502

Feeding Equipment Resource Information . . . . . . . . 505

Chapter 19 The Issues of Self-Feeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . 507

Readiness for Self-Feeding . . . . . . . . . . . . . . . . . . . . . . 507

Learning Self-Feeding . . . . . . . . . . . . . . . . . . . . . . . . . 508Bottle-Feeding . . . . . . . . . . . . . . . . . . . . . . . . . . . 508

Developmental Sequence . . . . . . . . . . . . . . . 508Bottle Variations . . . . . . . . . . . . . . . . . . . . . . 509Facilitation of Bottle Holding . . . . . . . . . . . 510

Finger-Feeding . . . . . . . . . . . . . . . . . . . . . . . . . . 511Postural Support for Finger-Feeding . . . . . 511Finger Foods . . . . . . . . . . . . . . . . . . . . . . . . . 511

Independent Spoon Feeding . . . . . . . . . . . . . . . 512“Spoonable” Foods . . . . . . . . . . . . . . . . . . . . 513Bowl and Spoon Options

in Spoon Feeding . . . . . . . . . . . . . . . . . . . 513Teaching Self-Feeding With a Spoon . . . . . 514

Independent Cup Drinking . . . . . . . . . . . . . . . . 516Teaching Cup Drinking . . . . . . . . . . . . . . . . 517Types of Liquid . . . . . . . . . . . . . . . . . . . . . . . 517Cup Variations . . . . . . . . . . . . . . . . . . . . . . . . 517

Straw Drinking . . . . . . . . . . . . . . . . . . . . . . . . . . 519Personal Exploration . . . . . . . . . . . . . . . . . . 519Teaching Straw Drinking . . . . . . . . . . . . . . . 519

Play and Self-Feeding . . . . . . . . . . . . . . . . . . . . . . . . . . 520

Self-Feeding for the Child With Physical Challenges . . . . . . . . . . . . . . . . . . . . 521

Readiness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 521Moving Toward Self-Feeding . . . . . . . . . . . . . . . 522

Self-Feeding for the Child With Sensory Challenges . . . . . . . . . . . . . . . . . . . . . 523

Readiness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 523Moving Toward Self-Feeding . . . . . . . . . . . . . . . 524

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Chapter 20 Feeding and Speech: A Question of Relationships . . . . . . . . . . . . . . 531

Parallel Versus Causal Relationships . . . . . . . . . . . . . . 531Feeding and Early Speech Sounds . . . . . . . . . . . 531Children with Feeding Problems . . . . . . . . . . . . 532Asking the Right Questions . . . . . . . . . . . . . . . . 534Mealtime and Feeding Strategies . . . . . . . . . . . . 535

Chapter 21 The Child Who Is Premature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 537

Developmentally Supportive Care . . . . . . . . . . . . . . . . 537

Feeding in the NICU . . . . . . . . . . . . . . . . . . . . . . . . . . . 538Nutrition Continuum for Premature Infants . . 538Readiness Factors for Nippling . . . . . . . . . . . . . 538

Color Changes . . . . . . . . . . . . . . . . . . . . . . . . 539Change of State . . . . . . . . . . . . . . . . . . . . . . . 539Breathing Changes . . . . . . . . . . . . . . . . . . . . 539Swallowing Difficulties . . . . . . . . . . . . . . . . . 540Motor Changes . . . . . . . . . . . . . . . . . . . . . . . 540

Nonnutritive Sucking . . . . . . . . . . . . . . . . . . . . . 540

Common Feeding Complications in Premature Infants . . . . . . . . . . . . . . . . . . . . . . . . 540

Medical Instability . . . . . . . . . . . . . . . . . . . . . 541Neurological Immaturity . . . . . . . . . . . . . . . 541Problems With State Regulation . . . . . . . . . 541Abnormal Muscle Tone . . . . . . . . . . . . . . . . . 541Immature or Altered Oral Mechanism . . . . 541Poor Oral Skills for Sucking

and Swallowing . . . . . . . . . . . . . . . . . . . . 542Oral Hypersensitivity . . . . . . . . . . . . . . . . . . 542Oral Hyposensitivity . . . . . . . . . . . . . . . . . . . 542Slowed Growth . . . . . . . . . . . . . . . . . . . . . . . 542Disruption in the Development

of a Positive Feeding Relationship . . . . . 542

Parent Involvement in Feeding . . . . . . . . . . . . . . . . . . 543Breast-Feeding . . . . . . . . . . . . . . . . . . . . . . . . . . 543Bottle-Feeding . . . . . . . . . . . . . . . . . . . . . . . . . . . 545Milk Delivery Alternatives . . . . . . . . . . . . . . . . . 545

Supplemental Nursing Systems . . . . . . . . . 545Finger-Feeding . . . . . . . . . . . . . . . . . . . . . . . . . . 545Cup Feeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . 546

Development of Feeding Skills . . . . . . . . . . . . . . . . . . 546Facilitating Coordination of Sucking

and Swallowing . . . . . . . . . . . . . . . . . . . . . . . 546Parent Guidance . . . . . . . . . . . . . . . . . . . . . . 546Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 546

Preparatory Sensory Stimulation . . . . . . . . 547Imposed Breaks . . . . . . . . . . . . . . . . . . . . . . . 547Bolus Size . . . . . . . . . . . . . . . . . . . . . . . . . . . 547Flow Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . 548Oral Support . . . . . . . . . . . . . . . . . . . . . . . . . 548

Demand Versus Scheduled Feedings . . . . . . . . . 549Facilitating Growth and Development

of Eating Skills in the Older Premature Infant at Home . . . . . . . . . . . . . . 549

Parental Guidance and Support . . . . . . . . . 549Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 550Prepare the Home Environment . . . . . . . . 551Oral Support . . . . . . . . . . . . . . . . . . . . . . . . . 551Transitions to Pureed Food . . . . . . . . . . . . . 551Transitions to Solids . . . . . . . . . . . . . . . . . . 552Monitor and Optimize Growth . . . . . . . . . . 552

Chapter 22 The Child Who Has Gastrointestinal Discomfort . . . . . . . . . . . . . . 555

Gastrointestinal Discomfort and Feeding . . . . . . . . . . 555Alicia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 556Partnership With Physicians . . . . . . . . . . . . . . . 557

Common Gastrointestinal Symptoms That Influence Feeding . . . . . . . . . . . . . . . . . . . . . . 557

Nausea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 557Gagging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 558Vomiting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 559Constant Fullness . . . . . . . . . . . . . . . . . . . . . . . . 560Retching . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 560Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 561Emotional Impact on the

Gastrointestinal System . . . . . . . . . . . . . . . . . 561Symptom Triggers . . . . . . . . . . . . . . . . . . . . . . . . 561

Understanding and Treating Gastrointestinal Discomfort . . . . . . . . . . . . . . . . . . 562

Understanding and Treating Esophageal Dysmotility . . . . . . . . . . . . . . . . . 562

Understanding and Treating Gastroesophageal Reflux . . . . . . . . . . . . . . . . 563

Symptoms of Gastroesophageal Reflux . . . . . . . 564Diagnosis of Gastroesophageal Reflux . . . . . 565Treatment of Gastroesophageal Reflux . . . . 566

Understanding and Managing Retching . . . . . . 569Reducing Retching . . . . . . . . . . . . . . . . . . . . 569

Understanding and Treating Poor Stomach Emptying . . . . . . . . . . . . . . . . 570

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Understanding and Treating Constipation . . . . 570Reducing Constipation . . . . . . . . . . . . . . . . . 571

Understanding and Treating Gagging and Vomiting . . . . . . . . . . . . . . . . . . 574

Medical Management . . . . . . . . . . . . . . . . . . 575Challenges for the Therapist . . . . . . . . . . . . 575

Understanding and Treating Poor Appetite . . . . 577Internal and External Regulators . . . . . . . . 577Why Is the Child’s Appetite Poor? . . . . . . . . 579

Gastroesophageal Reflux Parent Questionnaire . . . . . 581

Chapter 23 The Child Who Is Tube-Fed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 585

The Decision to Tube Feed a Child . . . . . . . . . . . . . . . 585Tube Feedings and the Family . . . . . . . . . . . . . . 585Tube Feedings and the Child . . . . . . . . . . . . . . . 586Reasons for Tube Feeding . . . . . . . . . . . . . . . . . . 587Feeding Tubes . . . . . . . . . . . . . . . . . . . . . . . . . . . 588

Enteral Tubes . . . . . . . . . . . . . . . . . . . . . . . . 588Parenteral Tubes . . . . . . . . . . . . . . . . . . . . . . 590Impact on Oral Motor Treatment

and Feeding . . . . . . . . . . . . . . . . . . . . . . . 590

Management of Tube Feedings . . . . . . . . . . . . . . . . . . 592Bolus or Continuous Drip Feedings . . . . . . . . . 592Positioning for Tube Feeding . . . . . . . . . . . . . . . 592Diet and Tube Feeding . . . . . . . . . . . . . . . . . . . . 593Tube Feeding Management Team . . . . . . . . . . . 594

Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 595Referral for Treatment . . . . . . . . . . . . . . . . . . . . 595

Feeding Therapy . . . . . . . . . . . . . . . . . . . . . . 595Traditional Oral Motor Therapy . . . . . . . . . . 595Comprehensive Oral Motor Treatment . . . . 595

Role of the Feeding Therapist . . . . . . . . . . . . . . 596Education . . . . . . . . . . . . . . . . . . . . . . . . . . . 596Ongoing Consultation . . . . . . . . . . . . . . . . . 597Family Support . . . . . . . . . . . . . . . . . . . . . . . 597Direct Oral Treatment . . . . . . . . . . . . . . . . . 597

Common Influences on Treatment . . . . . . . . . . 597Oral Experiences . . . . . . . . . . . . . . . . . . . . . . 597Medical Status . . . . . . . . . . . . . . . . . . . . . . . . 598Mealtime Interactions . . . . . . . . . . . . . . . . . 598Physical Skills . . . . . . . . . . . . . . . . . . . . . . . . 599Oral Skills . . . . . . . . . . . . . . . . . . . . . . . . . . . 599

Components of a Comprehensive Oral Motor Treatment Program . . . . . . . . . . . . . . . 600

Establishing a Positive Mealtime and Treatment Relationship . . . . . . . . . . . . . . . . . 600

Establishing a Relationship Between the Mouth and Feeding . . . . . . . . . 601

Reducing the Impact of Medical Conditions That Influence Feeding . . . . . . . . . . . . . . . . . 601

Optimizing the Comfort and Enjoyment of Tube Feedings . . . . . . . . . . . . . . . . . . . . . . . 602

Improving Postural Control of the Head, Neck, and Trunk . . . . . . . . . . . . . . . . . . . . . . . 603

Improving Control of the Pharyngeal Airway . . . . . . . . . . . . . . . . . . . . . 603

Using the Mouth to Explore the Environment . . . . . . . . . . . . . . . . . . . . . . 604

Normalizing the Response to Stimulation . . . . 604Identifying and Facilitating

a Swallowing Reflex . . . . . . . . . . . . . . . . . . . . 605Facilitating a Rhythmical Suckle-Swallow . . . . 606Improving Tone and Movement in the Jaw . . . . 607Improving Tone and Movement

in the Lips and Cheeks . . . . . . . . . . . . . . . . . . 607Improving Tone and Movement

in the Tongue . . . . . . . . . . . . . . . . . . . . . . . . . 607Facilitating Voicing and Sound Play . . . . . . . . . 607Programming Total Communication . . . . . . . . 608Creating a Learning Environment . . . . . . . . . . 608Timing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 610

Transition to Oral Feeding . . . . . . . . . . . . . . . . . . . . . . 610The Continuum From Tube Feeding

to Oral Feeding . . . . . . . . . . . . . . . . . . . . . . . . 610Readiness Factors . . . . . . . . . . . . . . . . . . . . . . . . 611

Resolution of the Original Problems . . . . . . 611Overall Health of the Child . . . . . . . . . . . . . 611Swallowing Safety . . . . . . . . . . . . . . . . . . . . . 611Status of Oral Skills . . . . . . . . . . . . . . . . . . . 612Hunger . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 612Child Readiness . . . . . . . . . . . . . . . . . . . . . . . 612Parent Readiness . . . . . . . . . . . . . . . . . . . . . . 612

The Continuum of Oral Preparation . . . . . . . . . 613From Nonfoods to Foods . . . . . . . . . . . . . . . 613Feeding Utensils . . . . . . . . . . . . . . . . . . . . . . 613Mealtime Modeling . . . . . . . . . . . . . . . . . . . . 614Dietary Preparations for Oral Feedings . . . . 614Hunger as an Ally . . . . . . . . . . . . . . . . . . . . . 615

Removing the Feeding Tube . . . . . . . . . . . . . . . . 616

Maturation and Change . . . . . . . . . . . . . . . . . . . . . . . . 616

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Chapter 24 The Child WhoRefuses to Eat Enough . . . . . . . . . . . . . . . . . . . . 619

The Personal Nature of Eating . . . . . . . . . . . . . . . . . . . 620A Layering of Issues . . . . . . . . . . . . . . . . . . . 621

Growth Issues: To Be Concerned or Not Concerned? . . . . . . . . . . . . . . . . . . . . . . . 621

Growth Charts . . . . . . . . . . . . . . . . . . . . . . . . 621Pediatric Undernutrition or

Failure to Thrive? . . . . . . . . . . . . . . . . . . . 623A Continuum of Concern . . . . . . . . . . . . . . . . . . 624

Layers of Influence . . . . . . . . . . . . . . . . . . . . . . . . . . . . 625The Now of Mealtime . . . . . . . . . . . . . . . . . . . . . 625Initial Influences: The First Layer . . . . . . . . . . . 626

Medical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 626Sensorimotor . . . . . . . . . . . . . . . . . . . . . . . . 627Mealtime Interaction . . . . . . . . . . . . . . . . . . 627Environment . . . . . . . . . . . . . . . . . . . . . . . . . 627

Interpretation and Action: The Second Layer . . . . . . . . . . . . . . . . . . . . . . 627

Trigger Events . . . . . . . . . . . . . . . . . . . . . . . . 627Beliefs and Interpretation . . . . . . . . . . . . . . 628Common Beliefs and Their Roots . . . . . . . . 630Is It a Behavior Problem? . . . . . . . . . . . . . . . 630

A Look at the Layers . . . . . . . . . . . . . . . . . . . . . . 631Andy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 631Tommy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 631Julia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 634Frankie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 636Darria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 636

Treatment Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . 639Addressing the Layers . . . . . . . . . . . . . . . . . . . . . 639

Identifying the Layers . . . . . . . . . . . . . . . . . . 640Making Changes . . . . . . . . . . . . . . . . . . . . . . 640Treating Underlying Physiological

Influences on Feeding . . . . . . . . . . . . . . . 640Understanding and Respecting

the Child’s Beliefs . . . . . . . . . . . . . . . . . . . 641Exploration and the Child’s

Relationship to Food . . . . . . . . . . . . . . . . 641Helping the Feeding Relationship . . . . . . . . 641

Mealtime Environments That Maximize Success . . . . . . . . . . . . . . . . . . . . . 642

Division of Responsibility . . . . . . . . . . . . . . . 642Meal-Snack Schedule . . . . . . . . . . . . . . . . . . 642Grazing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 642

Food Choices . . . . . . . . . . . . . . . . . . . . . . . . . 643Rejected Foods . . . . . . . . . . . . . . . . . . . . . . . 643Liquid Intake . . . . . . . . . . . . . . . . . . . . . . . . . 643Caloric Intake . . . . . . . . . . . . . . . . . . . . . . . . 644Mealtime Location . . . . . . . . . . . . . . . . . . . . 644Feeling Safe . . . . . . . . . . . . . . . . . . . . . . . . . . 644Exploration . . . . . . . . . . . . . . . . . . . . . . . . . . 645Small Steps . . . . . . . . . . . . . . . . . . . . . . . . . . 645Focus of Attention . . . . . . . . . . . . . . . . . . . . 645Novelty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 646Rules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 646Family Mealtimes . . . . . . . . . . . . . . . . . . . . . 646Team Support . . . . . . . . . . . . . . . . . . . . . . . . 646

Alternative Approaches . . . . . . . . . . . . . . . . . . . . 647

Chapter 25 The Child Who Has a Cleft Lip or Palate . . . . . . . . . . . . . . . . . . . . . . . 649

Clefts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 649Types of Clefts . . . . . . . . . . . . . . . . . . . . . . . . . . . 649Incidence of Clefting . . . . . . . . . . . . . . . . . . . . . . 650Etiology of Clefting . . . . . . . . . . . . . . . . . . . . . . . 650Team Support . . . . . . . . . . . . . . . . . . . . . . . . . . . 651Surgical Management . . . . . . . . . . . . . . . . . . . . . 651

Feeding the Child With a Cleft . . . . . . . . . . . . . . . . . . . 651Nutrition and Growth Patterns . . . . . . . . . . . . . 651The Mechanics of Sucking and

Swallowing With Clefts . . . . . . . . . . . . . . . . . 652Feeding Babies Who Have Clefts . . . . . . . . . . . . 652Breast-Feeding . . . . . . . . . . . . . . . . . . . . . . . . . . 653Bottle-Feeding . . . . . . . . . . . . . . . . . . . . . . . . . . . 654Palatal Obturator . . . . . . . . . . . . . . . . . . . . . . . . . 655Spoon Feeding . . . . . . . . . . . . . . . . . . . . . . . . . . . 656Textured Foods and Chewing . . . . . . . . . . . . . . . 656Older Children With a Cleft Palate . . . . . . . . . . 657Babies Who Continue to Have

Feeding Problems . . . . . . . . . . . . . . . . . . . . . . 657General Strategies for Feeding Children

With a Cleft Lip or Palate . . . . . . . . . . . . . . . . 657Focus on the Feeding Interaction . . . . . . . . 657Seek Simplicity . . . . . . . . . . . . . . . . . . . . . . . 657Identify and Incorporate Effective

Compensations . . . . . . . . . . . . . . . . . . . . . 658Move Slowly to Feeding Success . . . . . . . . . 658

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Chapter 26 The Child Who Has Visual Impairment . . . . . . . . . . . . . . . . . . . . 659

The Infant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 659Personal Exploration . . . . . . . . . . . . . . . . . . . . . 659Preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 659Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 660Mouthing! Mouthing! Mouthing! . . . . . . . . . . . 661Change Sensory Variables Slowly . . . . . . . . . . . 661Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 662

Mealtimes for the Older, Visually Impaired Child . . . . . . . . . . . . . . . . . . . . . . 663

Preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 663Routine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 663Exploration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 663Continue to Go Slowly

With Sensory Changes . . . . . . . . . . . . . . . . . . 664Familiarity . . . . . . . . . . . . . . . . . . . . . . . . . . . 664Separate Tastes . . . . . . . . . . . . . . . . . . . . . . . 664Reintroduce Rejected Foods . . . . . . . . . . . . 664

Incidental Learning and Imitation . . . . . . . . . . 664Teaching Independent Feeding . . . . . . . . . . . . . 665Personal Frame of Reference . . . . . . . . . . . . . . . 665Physical Success in Self-Feeding . . . . . . . . . . . . 666

Check Out the Supports . . . . . . . . . . . . . . . . 666Provide Hand-Under-Hand

Opportunities . . . . . . . . . . . . . . . . . . . . . . 666Provide Opportunities for

Trial-And-Error Learning . . . . . . . . . . . . 666Provide Guidance With

the Spoon Handle . . . . . . . . . . . . . . . . . . 666Provide Extra Elbow Support . . . . . . . . . . . 666Provide Hand-Over-Hand Help . . . . . . . . . . 666Use the Utility Handhold . . . . . . . . . . . . . . . 667Use Backward Chaining

to Build Success . . . . . . . . . . . . . . . . . . . . 667Fine-Tuning the Mealtime . . . . . . . . . . . . . . . . . 667Vision Loss and Severe Feeding Challenges . . . 668

Chapter 27 The Child Who Has Autism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 669

Sensory Variables and Mealtimes . . . . . . . . . . . . . . . . 670Heightened Sensitivities . . . . . . . . . . . . . . . . . . . 670Sensory Overload . . . . . . . . . . . . . . . . . . . . . . . . 671Motor Planning Deficits . . . . . . . . . . . . . . . . . . . 671

Communication Variables and Mealtimes . . . . . . . . . 671

Coping Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 673Picky Eaters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 673Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 673Limiting Transitions . . . . . . . . . . . . . . . . . . . . . . 673Feedback From Older Children and Adults . . . . 674

Nutrition and Growth . . . . . . . . . . . . . . . . . . . . . . . . . . 674Growth Worries . . . . . . . . . . . . . . . . . . . . . . . . . . 674Dietary Challenges . . . . . . . . . . . . . . . . . . . . . . . 675

Gastrointestinal Abnormalities . . . . . . . . . . 675Food Allergy . . . . . . . . . . . . . . . . . . . . . . . . . 676Central Nervous System Toxicity . . . . . . . . . 676Supplements . . . . . . . . . . . . . . . . . . . . . . . . . 677Dietary Implications

for Feeding Programs . . . . . . . . . . . . . . . 677

Sensory-Based Treatment . . . . . . . . . . . . . . . . . . . . . . 678

Making a Positive Difference at Mealtimes . . . . . . . . . 678Handling the Sensory Challenges

of Mealtimes . . . . . . . . . . . . . . . . . . . . . . . . . . 679Handling the Communication Challenges

of Mealtimes . . . . . . . . . . . . . . . . . . . . . . . . . . 681

Chapter 28 The Child Who Has Minimal Involvement . . . . . . . . . . . . . . . . . 683

The Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 683Drooling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 683Mouth Stuffing . . . . . . . . . . . . . . . . . . . . . . . . . . 684Delays in Expressive Speech and Language . . . 685The Underlying Sensorimotor Issues . . . . . . . . 685

Low Tone in the Trunk With Poor Postural Stability for Movement . . . . . . . 685

Poor Differentiation of Movement . . . . . . . . 686Poor Sensory Awareness

and Discrimination . . . . . . . . . . . . . . . . . 686Poor Attention . . . . . . . . . . . . . . . . . . . . . . . . 686Sensory-Processing Difficulties . . . . . . . . . . 686Motor-Planning Difficulties . . . . . . . . . . . . . 686

An Approach to Therapy . . . . . . . . . . . . . . . . . . . . . . . . 687Asking the Right Questions . . . . . . . . . . . . . . . . 687Mealtime and Feeding Strategies . . . . . . . . . . . . 687

Postural Stability and Control . . . . . . . . . . . 688Sensory Processing . . . . . . . . . . . . . . . . . . . . 688Increasing Attention . . . . . . . . . . . . . . . . . . . 688Differentiation of Oral Movement . . . . . . . . 689Motor Planning . . . . . . . . . . . . . . . . . . . . . . . 690

Choosing Snack Foods . . . . . . . . . . . . . . . . . . . . 690

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Chapter 29 Mealtime Resources . . . . . . . . . 691

Books on Mealtime and Feeding Development . . . . . 691

Videotapes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 693

Catalog . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 693

Internet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 694

Appendix A Pre-Feeding Global and Sequential Charts . . . . . . . . . . . . . . . . . . . . . 695

Appendix B Spanish Translations of Parent Questionnaires . . . . . . . . . . . . . . . . . . 727

Eating and Drinking . . . . . . . . . . . . . . . . . . . . . . . . . . . 729

Tube Feeding and Beginning Oral Feeding . . . . . . . . 733

Gastroesophageal Reflux . . . . . . . . . . . . . . . . . . . . . . . 738

Appendix C Mealtime Participation Experiences . . . . . . . . . . . . . . . . . 741

Physical Limitations No. 5: Retraction Patterns . . . . 743

Spoon Feeding No. 1: Smooth Food from a Spoon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 746

Spoon Feeding No. 15: Lip Variations in Spoon Feeding . . . . . . . . . . . . . . . . . . . . . . . . . . . 748

Imaginings: Sensory No. 12: Sensory Defensiveness to Touch in the Mouth . . . . . . . . . . . . . . . . . . . . . . . 751

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 755

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 783

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