Four Sensory Motor Aspects To Consider in Pediatric Feeding Therapy
Children first learn to eat before they talk. Feeding takes a course from liquids, to purees and finally solids. During the first year, infants learn to sit, crawl, stand and walk, a process that grades their motor coordination and postural stability. This process is interlinked with oral motor development required for talking and feeding, which is why babies start with fluids and progress to solid foods.
What we see on the outside as a feeding problem is only the tip of an iceberg (Figure 1), and what we can’t see is all that lies underneath that contributes to feeding disorders. It includes, all muscles, all organs, all senses, learning capacities, nutritional status, rate of development, and the environment, which requires careful consideration during a feeding program.
Breathing, Postural stability, oral sensory challenges, and oral motor strength are four sensory motor aspects that are most crucial to be considered during a mealtime.
In this blog I have listed them based on priority. I am not asking you to overlook the other aspects, but emphasizing these four aspects here as they are crucial to feeding and must not be taken lightly.
I) Breathing is a child’s number one priority. The oral musculature, pharynx and larynx are structures involved in breathing and are also involved in feeding. During the process of breathing air passes through the pharynx, and at the time of feeding the pharynx takes the role of passage for food-a complex process.
At mealtimes, take caution if children
a) Exhibit noisy breathing and/ or show distress before or after feeding
b) Change in skin colour around the lips, eyes, hands and/ or feet
c) Have increased rate of breathing
d) Show chest retraction and/or,
e) Have clammy skin.
These are some of the signs to watch out for in order to ensure you do not miss out any breathing difficulties during mealtimes.
II) Postural stability is Priority #2 and key to optimal breathing. There is a strong correlation between breathing, postural stability and oral motor movements required for complex feeding skills such as strength and efficiency to chew bigger and harder pieces of table food.
The right postural stability is achieved when the seating is right as illustrated in diagram 2. Ensure that there is a
a) 90 degree angle maintained at the ankle by resting the feet on the floor/ foot rest with anti-skid mat,
b) 90 degree angle maintained at the knees and hips. If the child is too small for the chair you may have to replace the chair and/ or provide support using cushions.
c) 90 degree angle at the level of the neck, to avoid any elevation during feeding to prevent aspirations.
I) Oral sensory challenges are seen in most children with developmental delays and must not me overlooked during meal times. This is Priority #3. Children with developmental delays may have one or more of the following sensory categories.
a) Oral hyposensitivity – an underreaction to tactile stimuli
b) Oral hypersensitivity – an overreaction to tactile stimuli
c) Mixed sensitivity – a combination of hyper and hyposensitivity
d) Fluctuating sensitivity – a mixed sensory component that can vary within months, weeks, days or even hours.
e) Oral defensiveness – typically seen in children who have an emotional reaction to tactile stimuli, as a result of being forced to feed or brush or other oral motor related activities - a learnt behavior, often seen in children with hypersensitivity.
II) Oral Motor Strength is Priority #4. This is a controversial aspect in feeding where some schools do not agree to oral motor strength training. However, in the last seventeen years of my practice I have found improving oral motor muscle strength to be very useful and have seen children progress much faster when oral motor strengthening is considered in therapy.
I will explain it using an illustration to make it clear.
An athlete may not be able to complete a 500 meters race as a winner, if he weren’t working on his exercise regime. He is as strong as his core muscle strength and other muscles that help him run the race.
Similarly, children need strengthening of their oral motor muscles, if there is/ are weakness(es) in order to be able to suck, chew or swallow. If muscles involved in feeding aren’t strong enough, chewing and swallowing food can become laborious. Identifying and strengthening jaw, lip and tongue strength and their range of movements is essential for a happy meal time.
If the jaw is in an open posture and/ or slides while speaking or eating, it is an indicator for jaw muscle weakness. Similarly, if lips don’t seal at rest, lip muscles need strengthening. When range of movement of the tongue is limited, work towards better tongue movements such as protrusion, retraction, lateralization, elevation, depression outside as well as within the mouth, focusing more on range of movement within the later.
Remember “stability is important for mobility”.
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