DEVELOPMENTAL DISABILITIES

RESEARCH REVIEWS 14: 105 117 (2008)

DEVELOPMENT OF SWALLOWING AND FEEDING:

PRENATAL THROUGH FIRST YEAR OF LIFE
Amy L. Delaney1* and Joan C. Arvedson2
1

Childrens Hospital of Wisconsin-Milwaukee, University of Wisconsin-Madison, Madison, Wisconsin

Childrens Hospital of Wisconsin-Milwaukee, Medical College of Wisconsin-Milwaukee, Milwaukee, Wisconsin

The development of feeding and swallowing involves a highly complex set of interactions that begin in embryologic and fetal periods and
continue through infancy and early childhood. This article will focus on
swallowing and feeding development in infants who are developing normally with a review of some aspects of prenatal development that provide
a basis for in utero sucking and swallowing. Non-nutritive sucking in
healthy preterm infants, nipple feeding in preterm and term infants, and
selected processes of continued development of oral skills for feeding
throughout the first year of life will be discussed. Advances in research
have provided new information in our understanding of the neurophysiology related to swallowing, premature infants sucking and swallowing
patterns, and changes in patterns from preterm to near term to term
infants. Oral skill development as texture changes are made throughout
the second half of the first year of life is an under studied phenomenon.
Knowledge of normal developmental progression is essential for professionals to appreciate differences from normal in infants and children with
feeding and swallowing disorders. Additional research of infants and children who demonstrate overall typical development in oral skills for feeding is encouraged and will provide helpful reference points in increasing
understanding of children who exhibit differences from typical development. It is hoped that new technology will provide noninvasive means of
delineating all phases of sucking and swallowing from prenatal through
infancy. Further related topics in other articles of this issue provide a comprehensive review of factors influencing oral intake, growth, nutrition,
' 2008 Wiley-Liss, Inc.
and neurodevelopmental status of children.
Dev Disabil Res Rev 2008;14:105117.

Key Words: infant; child; development; feeding; swallowing; sucking;

neurobiology

DEVELOPMENT OF SWALLOWING AND

FEEDING: PRENATAL THROUGH FIRST
YEAR OF LIFE
dequate respiration and nutrition are essential for all
living creatures. Successful and safe oral feeding in
neonates and young infants requires well coordinated
sucking, swallowing, and breathing sequencing. Breathing typically does not require active effort by infants except for those
with complicating factors that may include, but are not limited
to, bronchopulmonary dysplasia, upper airway obstruction as
in Pierre Robin sequence and other craniofacial anomalies,
and severe laryngotracheomalacia. Swallowing or deglutition
includes the entire act from food placement in the mouth
until the material enters into the stomach [Dodds, 1989;
Dodds et al., 1989; Logemann, 1998]. Logemann [1998]

' 2008 Wiley -Liss, Inc.

stressed that feeding (or eating) is distinct from swallowing.

Eating is primarily an oral phase function that includes oral
preparation and oral transit of a bolus. Feeding is described as
specific to anticipatory reactions, food getting, the placement
of food in the mouth, and bolus management, including
chewing (mastication) if necessary and the transfer of the bolus
with the tongue into the pharynx. In addition, feeding is a
broader term that includes the interactions between children
and their caregivers. Eating/feeding requires active effort by
infants who must have exquisite timing and coordination of
sucking, swallowing, and breathing to be efficient. Adequate
growth, defined by appropriate weight gain in early infancy and
for the first few years of life, is a primary measure of successful
feeding. An infant should take feedings efficiently in about 20
to no more than 30 min without stress to infant or feeder so
that the infant consumes sufficient volume to gain weight
appropriately. It is expected that infants feed at intervals of at
least 23 hr from the start of one feeding to the start of the
next feeding. This time interval is an important factor in the
facilitation of hunger, satiation at end of the feeding period,
digestion, and promotion of the next cycle. Infants need to
feed efficiently and safely to maintain stable respiratory health
and to make appropriate developmental gains over time.
Professionals involved with assessment and treatment of
infants and children with feeding and swallowing deficits must
have a thorough understanding of embryologic and developmental anatomy of the upper aerodigestive tract and the normal physiology of deglutition [e.g., Miller, 1982, 1999; Arvedson and Brodsky, 2002]. Research in recent years has added to
the understanding of the development of feeding and swallowing in utero and continuing through infancy [e.g., Ross and
Nyland, 1998; Gewolb et al., 2001a,b,c; Qureshi et al., 2002;
Miller et al., 2003, 2006].
Normal sucking, swallowing, and breathing sequencing
requires integration of multiple afferent and efferent systems in
the central nervous system (CNS). The most complex human

*Correspondence to: Amy L. Delaney, Childrens Hospital of Wisconsin, 9000 W.

Wisconsin Ave, PO Box 1997, MS #785, Milwaukee, WI 53201-1997.
E-mail: adelaney@chw.org
Received 23 May 2008; Accepted 23 May 2008
Published online in Wiley InterScience (www.interscience.wiley.com).
DOI: 10.1002/ddrr.16

Table 1. Selected Processes in Embryologic Period Relevant to Swallow Development

Number of Weeks Gestation

Process

Role in Swallowing

45

Endoderm of yolk sac incorporated into embryo to

form primordial gut
Mandible via 1st branchial arch
Oropharyngeal membrane ruptures to form
primitive choanae allowing for nasal breathing
Separation of esophagus and trachea from the
primitive foregut

Basis for separate esophagus and trachea

4
6
67

Growth important for tongue position and soft palate fusion

Nasal breathing critical for efficient nipple feeding (breast or
bottle)
Allows for liquid to move through esophagus without
aspiration

Adapted from Moore and Persaud, 2003.

neuromuscular unit in the body is the

upper aerodigestive tract that acts as a
conduit for passage of air and food.
Feeding and swallowing are the activities through which parents and care
providers first assess the overall health
and neurodevelopmental well-being of
neonates and young infants. In addition,
normal feeding patterns reflect the early
developmental pathways that are the
basis for later communication skills. The
interrelationship between feeding (in all
living beings) and complex verbal communication (unique to humans) is multifactorial and in need of continued
research. The study of comparative
anatomy and its implications for human
communication are well described
[Laitman and Reidenberg, 1993] and
will not be discussed further here. The
neurobiology of deglutition is discussed
by Arthur Miller and the neurophysiology of hunger and satiety is discussed
by Pauline Smith and Alastair Ferguson
in this issue.
The purpose of this review is to
describe some aspects of development
of normal feeding and swallowing from
prenatal periods through infancy. Topics
include the following: (1) prenatal development of sucking, swallowing, and
breathing coordination that is an important underpinning for oral feeding in
preterm and term infants; (2) developmental progression of oral feeding skills
at the breast or by bottle and nipple in
neonates and young infants; (3) oral
feeding skill development in the second
half of the first year of life. Transition
feeding skills emerge in typically developing infants by about 6 months of age,
at which time spoon feeding may be
introduced. Overall developmental skill
levels, not chronologic age, must be
taken into account when one considers
expectations for advancement of textures [e.g., Rogers and Arvedson,
2005]. The critical need for understanding the anatomy of the oral/pharyngeal/laryngeal/esophageal
mechanism
106

and the physiology of deglutition cannot be overstated, although that is not a

major focus for this review. Pediatric
specialists working with infants and
children with diverse feeding and swallowing problems must keep developmental milestones of typically developing infants and children in mind in
order to carry out evaluations that result
in optimal management decisions for
each unique child.
PRENATAL DEVELOPMENT OF
SUCK, SWALLOW, AND
RESPIRATION
The development of sucking and
swallowing can be appreciated first by
understanding the context of developmental changes in the embryonic (first
8 weeks of gestation) and fetal (week 9
to birth) periods. The neurodevelopmental maturation of cerebral and
brainstem pathways involved in swallowing underlie and contribute to the
readiness for oral feeding. The processes
will be discussed in relation to healthy
preterm and term infants.
Prenatal Age Estimations (Adjusted
Age)
Professionals need to keep prenatal age estimations in mind when setting
skill level expectations for preterm
infants readiness to feed orally and to
advance textures over time, given that
ages of preterm infants are typically
adjusted to the prenatal age estimate for
the first 24 months of life. It is common
to refer to the number of weeks in fetal
development as postconceptual age
(PCA) relating to the estimated day of
fertilization (fertilization age) or as postmenstrual age (PMA) relating to the
first day of the last normal menstrual
period (gestational age) [Moore and
Persaud, 2003]. PCA is expected to be
2 weeks shorter than PMA. There
may be confusion when age is described
in months, especially when it is not
known whether calendar months

Dev Disabil Res Rev

(2831 days) or lunar months (28 days)

are meant. However, it is more common for these ages to be described in
months.
Relevant Embryologic and Fetal
Development
Embryonic period (weeks 18)
All major organs and systems
form from three germ layers beginning
the fourth through the eighth week of
gestation making this the most critical
period of prenatal development. The
anatomy of the oral cavity, pharynx,
larynx, and esophagus is the result of
embryologic processes that begin at fertilization of the ovum and continue after birth. The beginnings of most essential external and internal structures are
formed during this period. Table 1
describes a few key processes relevant to
swallowing development. A human
appearance is evident by the end of the
8th week. Disturbances during this period may give rise to major congenital
anomalies.
Fetal period (week 9 to birth)
The fetal period is marked by
rapid body growth from the 9th week
to birth. Head growth is relatively slow
compared to growth in the rest of the
body. Differentiation of tissues and
organs continues [e.g., Moore and Presaud, 2003]. During this period, the fetus undergoes dramatic development of
swallowing, sucking, and oral sensorimotor function. The oral cavity, pharynx, and esophagus are three distinct
anatomic regions that can function separately but, in swallowing, they integrate their functions via a neuronal network. The anatomy and physiology of
normal swallowing is well described in
a number of resources [e.g., Bosma,
1986; Miller, 1999; Arvedson and
Brodsky, 2002]. A highly complex and
integrated sensorimotor system provides

DEVELOPMENT OF SWALLOWING AND FEEDING

DELANEY AND ARVEDSON

the foundation for functional sucking,

swallowing, and breathing.
Neurobiology of Oral Feeding and
Swallowing
Cerebral and brainstem pathways
involved in oral sensorimotor function
and swallowing [e.g., Yakovlev and
Lecours, 1967; Brody et al., 1987; Kinney
et al., 1988] as well as respiration
[Carroll, 2003] undergo developmental
maturation during the fetal period,
which continues after birth. Control of
swallowing occurs via multiple levels of
the nervous system [Miller, 1999].
Brainstem and cranial nerve development
The brain stem shows myelination
at 1824 weeks gestation. Roots of a
number of cranial nerves (CN) are myelinated during 2024 weeks gestation:
III (oculomotor), IV (trochlear), VI
(abducens), as well as the intramedullary
roots of cranial nerves VII (facial), IX
(glossopharyngeal), and XII (hypoglossal). These changes correspond with
the appearance of opening and closing
of the jaw, anterior tongue movements,
and suckling seen on ultrasound imaging after 18 weeks gestation [Miller
et al., 2003].
Peak synaptogenesis of the medulla is seen at 3436 weeks gestation.
By 3538 weeks, the nervous system
matures sufficiently to carry out some
integrative functions to include nipple
feeding as term approaches.
Sensory systems relevant to oral feeding
Sensory (afferent) cranial nerve
input to the brain-stem swallowing centers is provided primarily by CN V,
VII, IX, and X. The oral-pharyngeal
region has one of the richest and most
diverse sensory inputs of the entire
body [Miller, 1999]. Oral sensation
occurs via a range of modalities that
include taste, somesthetic sensitivity,
two-point discrimination, oral stereognosis, vibrotactile detection, proprioception, nociception, and chemical and
thermal sensitivity. Detailed descriptions
of each modality with its neural innervation and function can be found in
Miller [1999 pp 1333]. A variety of
sensory attributes are integral to oralmotor function to prepare liquid and
food for swallowing.
Taste is one of the most complex
sensations evoked from the oral-pharyngeal region. Miller [1999] suggests that
perception of taste may be more a flavor
than true taste since different modalities
contribute to taste perception. These
modalities include smell, touch, texture,
Dev Disabil Res Rev

temperature, and the chemical sense of

taste [Linden, 1993]. Taste and tactile
sensation in oral regions is well developed in fetal rats and sheep [Mistretta,
1972; Bradley and Mistretta, 1973].
Sensory fibers responding to taste synapse in the rostral nucleus tractus solitarius (NTS). Taste buds develop during
weeks 1113 in the human fetus, most
forming on the dorsal surface of the
tongue, with some on the palatoglossal
arches, palate, posterior surface of the
epiglottis, and the posterior wall of the
oropharynx. Stimulation of various
nerve branches that innervate the
tongue, including glossopharyngeal
nerve, along with the lingual branch and
the chorda tympani branch of the trigeminal nerve, evokes potentials in the
rostral region of the NTS [Blomquist
and Antem, 1965]. Neurons responding
to gustatory stimulation in the rat are
also found in the rostral region of the
NTS [Travers and Norgren, 1986]. Gustatory neurons are organized topographically. The majority of the NTS interneurons discharge to stimulation of taste
buds in specific regions.
The oral, pharyngeal, and esophageal regions are innervated by fibers that
respond to noxious stimuli. In humans,
the highest density of neural receptors
that respond to noxious stimuli is
located around the mouth and nose
[Miller, 1999]. Myelinated to unmyelinated fiber ratio is relatively high in the
trigeminal nerve, which suggests that
more myelinated fibers are involved in
innervating these receptors than in other
parts of the body [Miller, 1999]. Likewise, the oral and pharyngeal regions
have numerous sensory fibers responding
to changes in temperature [e.g., Storey,
1968a,b; Poulos and Lende 1970a,b].
Mechanical stimuli (touch and pressure)
are perceived over many more regions
of the oral cavity than are thermal stimuli with the tongue having a high density of mechanosensitive neurons.
Motor systems relevant to oral feeding
Primary motor (efferent) cranial
nerve input to the brain-stem swallowing
centers is provided primarily by CN V,
VII, IX, X, XII, and the upper cervical
(C1C3) nerves. Central pattern generators in specific regions of the brain stem
appear to control movements of mastication, respiration, and swallowing.
Development of the brain stem
network of interneurons controlling the
pharyngeal phase of swallowing appears
to reach a functional level in the fetus
[Miller, 1999]. Pharyngeal swallowing is
one of the first motor responses that

DEVELOPMENT OF SWALLOWING AND FEEDING

uses pharyngeal muscles and appears in

the fetal lamb [Bradley and Mistretta,
1973], in the fetal monkey [Minei and
Suzuki, 1976], and in the human fetus
by the 11th week [Hooker, 1954]. The
human fetus shows activity in the
tongue at about the same time as the
jaw-opening reflex.
Central pattern generators are
modulated by suprabulbar regions and
sensory feedback [Miller, 1999]. Swallowing can be evoked by multiple central pathways even after removal of the
entire cortical and subcortical regions
above the brain stem, which indicates
that the cerebral cortex is not essential
to the pharyngeal and esophageal phases
[Miller, 1982]. The cerebral cortex does
appear to facilitate the oral phase and
the initiation of the pharyngeal phase,
which requires exquisite timing of respiration and swallowing.
The relationship between the timing of respiration and swallowing has
been studied via transynatic neural tracers (cholera toxin horseradish peroxidase
[CT-HRP] and pseudorabies virus
[PRV]) that effectively label afferent terminal fields within the nucleus of the
solitary tract (NTS) as well as swallowing motor neurons and their dentritic
fields within the nucleus ambiguous
(NA), dorsal motor nucleus (DMN),
and the hypoglossal nucleus (XII)
[Broussard and Altschuler, 2000a,b;
Altschuler, 2001]. These authors stated
that their data provide an anatomic basis
for interaction of swallowing motoneurons with premotor neurons located in
the area of NA. Motoneurons that innervate all levels of the esophagus are
confined to the compact formation
(NAc). While the motoneurons projecting to the pharynx and cricothyroid
muscles are located in the semicompact
formation (NAsc), extensive bundling
of motoneuronal dendrites within the
NA supports the hypothesis that these
structures serve as networks for the generation of complex motor activities,
such as swallowing [Broussard and
Altschuler, 2000b]. A subpopulaton of
neurons in intermediate and interstitial
subnuclei of the NTS projects to pharyngeal motoneurons and buccopharyngeal PMNs and is synaptically linked
to esophageal peripheral motor neurons
(PMNs). This link between buccopharyngeal and esophageal PMNs provides a
potential anatomic substrate within the
NTS for the central integration of
esophageal peristalsis with the pharyngeal phase of swallowing and airwayprotective reflexes. Both human studies
and animal models that investigate

DELANEY AND ARVEDSON

107

esophagoglottal closure and pharyngoupper esophageal sphincter (pharyngoUES) contractile reflexes have located
the neural pathways that mediate airway
protective reflexes. Additional research
using this same paradigm may help to
demonstrate the central integration of
swallowing and airway protective
reflexes in infants and young children as
well as adults [Broussard and Altschuler,
2000a].
Effect of decreased sensory input on motor
function
Short-term decrease in oropharyngeal sensory input to adults has been
shown to impede cortical control for
swallowing through magnetoencephalography (MEG) [Teismann et al.,
2007]. Teismann et al. found decreased
motor activation apart from a strongly
reduced sensory representation. Significantly increased swallowing related
muscle activation during an anesthesia
was found compared to swallowing
without anesthesia. Up to about 10
years ago many thought that swallowing
was coordinated only by the brainstem.
Functional brain imaging methods have
proved the influence of several cortical
areas on deglutition [Hamdy et al.,
1999; Mosier et al., 1999; Dziewas
et al., 2003]. Although this line of
research is with adults, it is hoped that
similar research paradigms may aid in
increasing understanding of the developing brain.
Sensory input for infants. Breathing, sucking, and swallowing activities occur in
the upper aerodigestive tract and are
orchestrated by specific areas in the
CNS. When pharyngeal and laryngotracheal sensation is reduced, aspiration is
likely to occur with no overt manifestations, that is, silent aspiration. Research
findings have challenged the assumption
that healthy newborn infants cough
with aspiration [Perkett and Vaughan,
1982; Pickens et al., 1988]. Predominant responses of sleeping infants stimulated by introduction of a small bolus
(0.1 ml) of water or saline into the
pharynx via a nasal catheter are swallowing, apnea, and laryngeal closure.
Coughing is rare [Pickens et al., 1988].
Research on neonatal development of
cough involves studies of the laryngeal
chemoreflexes (LCR) that are stimulated by fluid contacting the mucosa of
the larynx. These reflexes are initiated
in the fetus and newborn when hypochloremic or strongly acidic solutions
contact the epithelium that surrounds
the entrance to the laryngeal airway
108

[Thach, 2001]. The LCRs include startle, rapid swallowing, apnea, laryngeal
constriction, hypertension, and bradycardia. Several responses make up the
LCR reflex. The most common
response is one or more swallows,
slightly less common is apnea that may
or may not be accompanied by laryngeal closure as inspiratory efforts are
obstructed. The probability of a cough
response increases in frequency with
maturation. As the infant matures, rapid
swallowing and apnea become less pronounced, whereas cough and possibly
laryngeal constriction become more
prominent. This transformation relates
primarily to central neural processing
rather than to changes in the airway
mucosal water receptors that initiate
the reflex [Thach, 2001, 2007]. Clinicians must keep these findings in mind
during interpretation of instrumental
swallow examinations for young infants
during which there may be occasional
trace silent aspiration. In some instances,
this may not necessarily be a major
problem. Further data are needed, particularly outcomes data on infants who
continue to feed orally.
Prenatal Sucking, Swallowing,
and Breathing
Ultrasound studies of fetuses have
revealed early development of swallowing and oral sensorimotor function
[e.g., Ross and Nyland, 1998; Miller
et al., 2003]. Fetal swallowing is important for the regulation of amniotic fluid
volume and composition, recirculation
of solutes from the fetal environment,
and maturation of the fetal gastrointestinal tract [Ross and Nyland, 1998]. The
pharyngeal swallow is one of the first
motor responses in the pharynx and has
been reported between 10 and 14
weeks gestation [Humphrey, 1967;
Devries et al., 1985; Cajal, 1996].
Ultrasound studies reveal non-nutritive
sucking and swallowing in most fetuses
by 15 weeks gestation. The fetus
absorbs some amniotic fluid after swallowing it. A suckling response may be
elicited at this stage as reported in spontaneously aborted fetuses [Moore and
Persaud, 2003]. Forward tongue thrusting has been reported by 21 weeks gestation, tongue cupping at 28 weeks gestation, and suckling (anterior-posterior
tongue movements) between 18 and 24
weeks gestation. Self oral-facial stimulation is shown to precede suckling and
swallowing [Miller et al., 2003]. Consistent swallowing is seen by 2224
weeks gestation [Miller et al., 2003].
The near term fetus swallows amniotic

Dev Disabil Res Rev

fluid at a volume of about 5001,000

ml/day [Ross and Nyland, 1998].
Substantial weight gain occurs
from 21 to 25 weeks. By 24 weeks, surfactant is being secreted to maintain the
patency of the developing alveoli of the
lungs. The respiratory system is still
immature and may not be viable (viability is defined as the ability of a fetus to
survive in the extrauterine environment).
By 2629 weeks, the lungs are capable of breathing air. The CNS can
direct rhythmic breathing movements
and control body temperature by this
period. Fetal responses can be induced
by bitter-tasting substances at 2628
weeks, indicating that reflex pathways
are established between taste buds and
facial muscles. [Moore and Persaud,
2003]. Taste can alter frequency of
suckling motions.
Sex-related differences across 2nd
and 3rd trimesters are found for early
oral, lingual, pharyngeal, and laryngeal
motor activities via sonographic images
of 85 healthy fetuses at 24 weeks 3 days
(SD 0.69) [Miller et al., 2006]. Males
(N 5 43) and females (N 5 42) demonstrated statistically similar patterns of
general physical growth, but significant
differences were found in development
of specific lingual and pharyngeal structures, laryngeal and pharyngeal motor
activity, and oral-lingual movements.
Complex oral-motor and upper airway
skills emerged earlier in females, suggesting a sex-specific trajectory of
motor development [Miller et al.,
2006]. Pharyngeal and laryngeal movements in males were less rhythmic and
complete than in females throughout
the second trimester. By the third trimester, these movements became more
similar. Overall, females attained oralmotor skills at earlier stages of prenatal
maturation. These authors concluded
that differential patterns of prenatal
motor development may be important
in defining sex-specific indices of oral
skill maturation. Additional data are
needed.
Preterm infant feeding
A normal-weight fetus born at 32
weeks is premature by date as
opposed to premature by weight
[Moore and Persaud, 2003]. A healthy
preterm delivery may result in total oral
feeding by 34 weeks gestation. Growth
slows as the fetus nears term. Infants
delivered in this near-term period are
typically total oral feeders, although
some show evidence of mild disorganization of sucking, swallowing, and

DEVELOPMENT OF SWALLOWING AND FEEDING

DELANEY AND ARVEDSON

Table 2. Infant Readiness for Oral Feeding on Basis of

Behavioral Organization States
State

Behavioral Organization State Related to Feeding Readiness

1
2
3a
4a
5a
6

Deep sleep, seldom seen in a preterm infant

Light sleep
Drowsy
Quiet awake and/or alert
Actively awake and aroused
Highly aroused, agitated, upset and/or crying

Behavioral organization states optimal for oral feeding. Adapted from Als, 1985, 1986; Brazelton and Nugent, 1995.

breathing coordination for the first couple weeks of life. The course toward
oral feeding is different in preterm
infants delivered at shorter gestation.
Preterm infant feeding development
The first concerns following preterm delivery relate to stabilization of
respiration to support life. Infants without major cardiorespiratory or GI tract
deficits are appropriate for introduction
to non-nutritive sucking, usually via
pacifier, as early as 2829 weeks PCA.
Some infants who are intubated orally
are noted on ulstrasound to suck on the
tube, likely a continuation of sucking
that is noted in utero as the fetus can be
seen to suck fingers or suck on the
tongue.
Non-nutritive sucking: Indicator of oral
feeding readiness in preterm infants
One of the most complicated
tasks required of a newborn infant is
oral feeding that involves complex integration of anatomic structures to
include lips, jaw, cheeks, tongue, palate,
pharynx, and larynx. Coordinated
rhythmic sequences of sucking, swallowing, and breathing are required of
infants whether they are breast- or bot-

tle-fed. The survival rates of preterm

infants have improved significantly in
recent years, but one of the most common and urgent care issue that continues, is the subject of when and how to
initiate and to advance oral feedings.
The ability to make a transition from
gavage to oral feeding depends on neurodevelopmental status related to behavioral organization (Table 2), to cardiorespiratory regulation, and to the ability
to produce a rhythmic suck-swallowbreathe pattern. Healthy term infants
have that ability, but preterm infants less
than 32 weeks PCA are neurologically
immature and rarely they are capable of
that coordination. Preterm infants can
become stressed with bottle feeding for
several reasons to include, but not limited to, (1) neurological immaturity, (2)
difficulty regulating autonomic functions, and (3) difficulty achieving behavioral state organization when they
are presented with stimuli [Als and
Brazelton, 1981; Brazelton and Nugent,
1995]. Oral feeding is usually optimal
when an infant is drowsy, in a quiet
awake and alert state, or actively awake
and aroused. When an infant is in deep
sleep (seldom seen in preterm infants)
or in light sleep, on one hand, or highly

aroused or agitated on the other hand,

feedings do not typically go smoothly
and easily because the behaviors interfere with suck, swallow, and breathe
sequencing.
Non-nutritive sucking (NNS)
success is commonly used as one of the
markers of readiness for an infant to
feed by bottle [Pinelli and Symington,
2001], although only a few studies have
examined the relationships between the
characteristics of NNS and nutritive
sucking (NS). Most infants are given
NNS experiences via pacifier. Studies
have demonstrated positive effects of NNS
via pacifier in multiple ways (Table 3).
Fucile et al. [2002] reported that their
experimental group of preterm infants
reached independent oral feeding 1
week earlier than a sham group with no
intervention when specific stimulation
of oral structures was carried out for 15
min once per day for 10 days starting
48 hr after discontinuation of CPAP.
However, there was no difference in
length of stay between the two groups.
Similarly, Bragelien et al. [2008] reported that a stimulation program did
not result in earlier weaning from NG
tube feedings in premature infants or
earlier discharge when compared to
similar infants with no intervention. It
would be of interest to have a comparison group receiving some other type of
hands on intervention, e.g., soothing
touch to other body parts with a question of potential for facilitating oral
feeding. This comparison has been
shown for reducing pain during heel
stick with saturation levels maintained
significantly better in Yakson (a traditional Korean touching method) and
NNS group compared to control group
neonates [Im et al., 2008]. These
authors found no difference among the
groups with regard to heart rate and

Table 3. Outcomes Associated with NNS via Pacifier for Preterm Infants
Authors

Outcome

Paludetto et al., 1984

Burroughs et al., 1978
Treloar, 1994
Field and Goldson, 1984; South et al., 2005; Im et al.,
2008
Field et al., 1982; Gaebler and Hanzlik, 1996
Bernbaum et al., 1983
Measel and Anderson, 1979
Field et al., 1982
DiPietro et al., 1994; McCain, 1995
Standley, 2003
Pickler and Reyna, 2004

Increased transcutaneous oxygen tension between 32 and 35 weeks gestation

Promoting oxygenation
Higher transcutaneous oxygen tensions [tcPO2s] after crying induced by heelstick
Soothing during invasive procedures (less fussing and crying); Pain reduction during heel
stick procedure
Shorter transition from tube to oral feeding; shorter hospital stay
Maturing suck pattern, enhanced growth and maturation
Improved digestion by simulating the natural way nutrients are ingested
Weight gain
Regulating state and facilitating optimal behavioral state for feeding
NNS with music significantly increased feeding rate
Prefeeding NNS had no effect on NS, breathing during feeding, or select behavioral
characteristics of feeding

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DEVELOPMENT OF SWALLOWING AND FEEDING

DELANEY AND ARVEDSON

109

pain measured by the Neonatal Infant

Pain Scale, but they did not use any
measures to compare oral feeding
aspects.
Comparison of non-nutritive and nutritive
sucking in a preterm infant
In contrast to previously held
beliefs, Miller and Kang [2007] reported
that lingual patterns on ultrasound
showed significantly greater displacements and excursions when a preterm
infant was sucking for nutritive purposes (NS) compared to NNS on a pacifier. The angle of the hyoid movement
was significantly greater with NS than
with NNS. Vertical tongue body excursions occurred similar to those previously considered at 69 month developmental skill levels. These authors suggested that technical advances in
noninvasive ultrasound imaging techniques with integration of semiautomatic
computerized analyses of tongue surface
configurations and hyoid activity provide means to enhance knowledge of
oral swallowing function in early phases
of preterm infant development.
Facilitation of oral feeding (breast and bottle)
The movements of non-nutritive
sucking and swallowing in preterm
infants are characterized by organized
bursts of lingual movement separated by
brief pauses in motor activity [Wolff,
1968; Daniels et al., 1986]. These
movements represent ontogenetic maturation of morphologic and neurological
systems [Hafstrom and Kjellmer, 2000;
Miller et al., 2003]. The readiness for
oral feeding is related to behavioral state
organization [Als, 1985, 1986] (Table
2), to a rhythmic suck-swallow-breathe
pattern, and to cardiorespiratory regulation [McCain, 2003]. Some infants do
appear ready to begin oral feeding at
3233 weeks gestation [Cagan, 1995;
McCain, 2003], although 34 weeks gestation is often used as the lower limit of
expectations for full oral intake to meet
nutrition and hydration needs.
Developmental patterns of rhythmic sucking and swallowing in preterm
infants have been outlined by Gewolb
et al. [2001a] who used intranipple and
pharyngeal pressure recordings. They
found that swallow rhythm is established
as early as 32 weeks PMA and does not
change through 40 weeks PMA.
Although the swallow rhythm does not
change, the stability of the suck rhythm
increases steadily from 32 to 40 weeks
PMA. At 32 weeks PMA, sucking is
rapid and of low amplitude, not linked
to swallowing. By 33 weeks PMA,
110

sucking is irregular with an average of

23 sucks per sec and not linked with
swallowing. Transitions occur during
week 34. From 35 to 40 weeks PMA,
infants have well-defined sucks occurring at 1 suck per sec and suck/swallow
sequences appear well established. The
ratio of 1 suck to 1 swallow predominates in infants until they are beyond 40
weeks PMA. At that age it is not unusual for 23 sucks per swallow to
occur [Qureshi et al., 2002]. These
changes may reflect a pattern of maturation representing the process of encephalization with infants maturing to alter
their feeding strategies qualitatively from
a pattern that has had some reflexive
feeding rhythm characteristics [Bosma,
1986]. The maturation of sucking and
swallowing from preterm to term and
beyond is characterized by increased
sucking and swallowing rates, longer
sucking bursts, and larger volumes per
suck [Mathew, 1991; Schrank et al.,
1998; Lau et al., 2000, 2003; Gewolb
et al., 2001a,c; Qureshi et al., 2002;
Mizuno and Ueda, 2003; Gewolb and
Vice, 2006].
Feeding experience appears to be
the best predictor of feeding outcomes
[Pickler et al., 2005, 2006], with the
number of sucks in the first suck burst
also contributing significantly to feeding
outcomes [Pickler et al., 2006]. Pickler
and Reyna [2003] suggest that achievement of full bottle feedings may be
facilitated by increased bottle-feeding
opportunities, given the inverse relationship found via number of bottle
feedings received per day during transition from the first bottle feeding to full
bottle feedings and length of transition
to full bottle feedings in 25 preterm
infants. Crosson and Pickler [2004]
reviewed the literature on demand feedings for preterm infants. They found
that the seven studies in the previous 50
years used a variety of research methods
with interpretation difficulties because
of inadequate sample sizes and incomplete descriptions of methodology in
some studies. They concluded that
overall findings support cautious contention that demand feeding might
prove to be the feeding approach of
choice for most healthy preterm infants.
In contrast, Tosh and McGuire [2006]
concluded following a standard search
strategy of the Cochrane Neonatal
Review Group that there are insufficient data to guide clinical practice as of
the date of their review. They urged a
large randomized controlled trial to
focus on infants in the transition phase
from gavage to oral feeding that should

Dev Disabil Res Rev

be of sufficient duration to assess effects

on growth and time to oral feeding and
hospital discharge.
Oral feeding at term and during first few
months of life. Healthy premature infants
at their expected delivery date and
infants delivered at term during the first
week of nipple feeding are likely to
have intermittent decreased minute ventilation, respiratory rate, and tidal volume during oral feeding. During the
next few months, infants refine their
skills and increase efficiency so that they
maintain feeding durations while they
consume a greater volume appropriate
for their weight gain and growth.
Regardless of age, the majority of
infants swallows are followed by expiration [Kelly et al., 2007].
The anatomy of oral and pharyngeal structures in the first few months
of life underlies and facilitates nipple
feeding. The mandible is disproportionately small compared to the skull. The
tongue fills the oral cavity and contacts
all surfaces leaving little space for variation in tongue movements. The fat pads
in the cheeks narrow the oral cavity in
the lateral dimension [Kennedy and
Kent, 1985; Bosma, 1986; Arvedson
and Brodsky, 2002]. The posterior onethird of the tongue lies within the oral
cavity as the larynx is positioned much
higher in the pharynx than in the adult
structure without the 908 angle separating the oral and pharyngeal cavities and
the approximation of the soft palate and
epiglottis. This positioning of the larynx
high and under the tongue base affords
the infant some protection, but not
total protection, from aspiration of liquid into the lungs. This anatomic configuration supports the act of suckling,
defined as backwardforward tongue
movement to extract liquid from the
breast or bottle [Bosma, 1986; Arvedson
and Brodsky, 2002].
Infants delivered at term typically
take only breast milk or formula via
nipple during the first few months of
life. According to the American Academy of Pediatrics (AAP) [Samour and
King, 2006], infants in the first month
of life average 75 ml (2.5 oz) formula
or breast milk per 450 g (pound) of
body weight per day over 78 feedings
lasting 1520 min at 23 hr intervals.
Typical infants increase the amount of
breast milk or formula by 30 ml (1 oz)
per month until 69 months when they
take 240 ml (8 oz) per feeding 34
times per day [Samour and King, 2006]
(Table 4). By 6 months of age, these
infants taking smooth pureed food by

DEVELOPMENT OF SWALLOWING AND FEEDING

DELANEY AND ARVEDSON

Table 4. Typical Number of Bottle/Breast Feedings per Day and

Range of Formula Intake
Age (months)

Number of Feeds per Day

Range of Intake per Feeding

<1
13
36
69
912

78
57
45
34
3

24
46
67
78
78

ounces
ounces
ounces
ounces
ounces

(60120 ml)
(120180 ml)
(180210 ml)
(210240 ml)
(210240 ml)

Adapted from Samour and King, 2006.

spoon are still getting 80% of nutrition

needs met by formula or breast milk
with decrease to 50% by 10 months of
age [e.g., Samour and King, 2006]. Efficient infants and children spend 30 min
or less at mealtimes [Reau et al., 1996].
The AAP Committee on Nutrition recommends that infants are given
iron-fortified formula or breast milk
until 12 months of age for optimal
nutrition status [AAP, 1999]. Cows
milk before 12 months of age increases
the risk for iron deficiency anemia,
milk protein allergy, gastrointestinal
blood loss, and inadequate nutrition.
No nutrition supplement is
required until 6 months of age as term
infants usually have adequate iron stores
until then, whether they are breast or
bottle fed [Griffin and Abrams, 2001;
Samour and King, 2006]. By 6 months
of age, caloric requirements are not
always satisfied with formula or breast
milk alone. Total breast-fed infants
require iron and zinc supplements, usually by introduction of iron-fortified
infant cereal and pureed meats by spoon
[Fomon, 2001; Samour and King, 2006;
Krebs, 2006]. The transition to spoon
feeding is an important milestone for
developmental skill purposes and nutrition well-being.
Preterm infant age adjustments after birth
Preterm infants should be given
the benefit of their adjusted ages for the
first 24 months of life. In addition,
functional levels relating to gross and
fine motor skills, cognitive skills, and
language and speech skills, must all be
taken into account when determining
expectations for oral feeding recommendations. The expectations for feeding skills and swallowing safety are estimated in relation to both adjusted age
and overall developmental status. Differences become particularly important
when determining readiness for advancing textures. When overall developmental skill levels (gross and fine motor
skills as well as cognitive and speech/
Dev Disabil Res Rev

language skills) are below chronologic

age (or adjusted age for children born
prematurely), feeding and swallowing
specialists should guide parents and
other professionals in ways that help
them to appreciate fully the relationship
of oral feeding skills and global developmental levels. For example, a child at 12
months chronologic age, 9 months
adjusted age (born at 26 weeks gestation) and not yet sitting independently
(expected by 6 months), is not expected
to chew and swallow solid food. This
child realistically would be expected to
have oral feeding and swallowing skills
equivalent to a typically developing
infant at about 6 months of age. At that
age, nipple feeding continues to be the
primary means of meeting nutrition and
hydration needs with spoon feeding for
practice and developmental skill
advancement. In addition to the skill development that infants experience during the first year of life, they also participate in reciprocal feeding or mealtime
relationships that change over time.
Relationship changes relevant to feeding
development
Feeding during infancy is a reciprocal process that depends on specific
abilities and characteristics of caregivers
and infants with a give-and-take
exchange. Normal feeding development
includes the following three stages: homeostasis (02 months), attachment
(36 months), and separation/individuation (636 months) [Chatoor et al.,
1984]. A healthy positive feeding relationship is critical for successful feeding.
Caregivers need to understand the process in the young infants achievement
of some degree of self-regulation during
the stage of homeostasis. Caregivers
must recognize and respond promptly to
hunger cues, and they should assist the
infant in regaining an organized state after becoming overstimulated or upset.
During the stage of attachment, infants
begin to engage interest of other people
in interactional patterns [Greenspan and

DEVELOPMENT OF SWALLOWING AND FEEDING

Lourie, 1981] with feeding becoming a

social time. Pauses after sucking bursts
during nipple feedings become more
obvious. Feeders may interpret those
pauses as the infant signaling a need to
burp or indicating satiety, whereas the
infant may be pausing as a cue for
socialization. Infants begin to exert
more control over their environment by
about 6 months of age at the beginning
of the separation/individuation period.
From 6 months to 36 months, the primary behavioral development is a struggle to attain a sense of self. Caregivers
provide boundaries, structure, and limits
that allow a child to explore safely. A
common challenge at meal times during
this time involves a balance between
autonomy and dependency.
Although this article focuses on
the infant and young child for oral skill
development while stressing the importance of swallowing efficiently without
risks for aspiration, successful feeding
also requires appropriate reciprocal relationships among caregivers and children.
The complexities of feeding in typical
children and those with feeding and
swallowing problems involve multiple
factors, all of which must be considered
for caregivers to make decisions regarding optimal facilitation of safe and nonstressful feeding. The need for knowledge of normal development continues
to be important as typical children reach
the second half of the first year of life
and become ready for transition feeding.
Changes in second half of first year: Transition feeding. Infants demonstrate readiness for transition feeding when they
are 6 months of age, or when their
overall developmental skills are at that
level, usually including the ability to
maintain an upright posture for a short
time when placed in a sitting position.
Anatomic changes have occurred
as growth of the oral cavity and lowering of laryngeal structures provides
more space in the oral cavity. With
elongation of the pharynx and descent
of the larynx, a 908 angle of the oralpharyngeal complex occurs as the posterior 1/3 of the tongue descends into
the pharynx. The fat pads are absorbed
and disengagement of the soft palate
and epiglottis occurs. These anatomic
changes allow for increased movement
of the oral structures that aid in the
transition from the early pattern of
suckling to sucking and the introduction of spoon feeding. Sucking is characterized by the tongue showing vertical movement to extract liquid with
only small vertical movement of the jaw

DELANEY AND ARVEDSON

111

and firmer approximation of the lips

[Bosma, 1986; Arvedson and Brodsky,
2002]. With the change in direction of
tongue movement during sucking, the
child is ready for transition to foods
other than liquids. As additional
research is carried out, perhaps the case
study report with vertical tongue action
noted in a preterm infant on ultrasound
may provide added support for that
finding [Miller and Kang, 2007].
Critical and sensitive periods affecting
expansion of diet textures
Critical periods have been
described for chewing and for taste.
The critical period for chewing is that
time following the disappearance of the
tongue protrusion reflex that should
occur around 6 months of age [Illingworth and Lister, 1964]. The tongue
protrusion reflex is characterized by
pushing food out of the mouth when it
is placed on the anterior tongue. Most
children have difficulty in learning specific oral movements if these new textures are introduced after the critical
period has passed. When textured foods
are introduced after 10 months of age,
children are more likely to refuse solids.
They consume inadequate volumes of
food and are choosy about the foods
they accept at 15 months of age
[Northstone et al., 2001].
Critical periods have also been
reported for introduction of tastes.
Newborn infants detect sweet solutions,
reject sour flavors, and are indifferent to
the taste of salt [Mennella and Beauchamp, 1998]. By 4 months of age,
infants recognize salt water relative to
plain water and over the next 2 years
changes in taste response occur. By 18
months, children begin rejecting salt
water in preference for salt in table
foods [Mennella and Beauchamp, 1998].
Children first introduced to fruits
showed preference for fruits over vegetables. However, multiple exposures to
varied foods increased their overall acceptance and intake [Sullivan and Birch,
1994; Forestell and Mennella, 2007].
Breast-fed children have been reported
to have less prominent food selectivity
than formula-fed due to exposure to
multiple flavors from the breast milk if
the mother frequently consumed those
foods [Forestell and Mennella, 2007].
Likewise difficulties in introducing
unpleasant tasting protein hydrolysate
formulas during older infancy (at 7
months of age) may relate to early limited experiences with multiple flavors
for infants on milk based formulas
[Mennella et al., 2004].
112

Table 5. Selected Motor Skills (Gross, Fine, and Oral) in

Children During Transition Feeding Development
Mean age (months)

Motor Skill

45

Sit on caregivers lap without help

Reach for spoon when hungry
Open mouth when spoon approaches or touches lips
Move tongue gently back and forth as food enters mouth
Use tongue to move food to back of mouth to swallow
Keep food in mouth; no refeeding
Transfer toys and foods from one hand to the other
Feed self cracker or cookie
Crawl on hands and knees
Turn upper body from sitting to crawling
Eat finger foods without gagging
Use fingers to rake food toward self
Put fingers in mouth to move food and keep it in the mouth
Eat foods with tiny lumps without gagging
Chew softer foods, keeping most in mouth
Walk without help
Poke food with index finger
Chew firmer foods, keeping most in mouth

68
810

1012

Adapted from Carruth and Skinner, 2002.

Anatomic and sensory changes

Eruption of teeth is an important
anatomic change in late infancy. The
teeth assist in biting and grinding of
more textured foods.
Dentition is thought to play a
crucial role as sensory receptors during
biting and chewing [Bosma, 1986;
Arvedson and Brodsky, 2002]. Onset of
tooth eruption is expected for mandibular incisors (68 to 1213 months),
molars (1224 months), and canines
(1620 months) [Bosma, 1986; Arvedson and Brodsky, 2002].
Introduction of spoon feeding
The introduction of spoon feeding of thin smooth pureed food occurs
once a child reaches about a 6-month
level developmentally. Foods are introduced one at a time in a specific order
per guidelines by dietitians that permit
observations for potential food allergies
[Fomon, 2001; Fiocchi et al., 2006;
Samour and King, 2006]. The American
Dietetics Association recommends a
thin rice infant cereal as the first food
because it is an unlikely allergen. Single
ingredient foods (such as commercial
Stage one thin pureed food in the U.S.
or well blended smooth food) should be
introduced one at a time after cereal to
test for food allergies. Combination
foods that are smooth pureed foods
(e.g., Stage two baby foods in the U.S.)
can be introduced after all single ingredient foods have been offered usually
between 7 and 9 months of age. Gradually food with texture are added, such
as, dissolvable solids (e.g., soft cracker at

Dev Disabil Res Rev

69 months), textured puree foods

(e.g., mashed banana, cottage cheese at
69 months), ground solids at 69
months, soft diced solids (e.g., fruits and
vegetables at 912 months), and eventually a general toddler diet of table foods
by 1218 months of age.
In the U.S. and some other countries, a spout cup is introduced between
6 and 9 months as a beginning step in
weaning from the breast or bottle. Children are more likely to be successful
with cup drinking if a spill-proof valve
is not used until a child has learned to
suck actively to extract liquid. By 12
months, children are generally receiving
their fluids through a combination of
bottle or breast feeding and cup with a
valve or a straw. Children are expected
to drink independently from a spout
cup or straw, usually by their first birthday. Independent drinking from an
open cup usually occurs later.
With these feeding transitions, general motor development and oral feeding ability are shown to relate closely
although a one-to-one relationship has
not been established (Table 5) [Carruth
and Skinner, 2002; Koda et al., 2006].
With broad developmental gains in
gross motor function, children can
improve stability through the trunk,
neck, and shoulder musculature to
increase mobility of extremities for selffeeding activities These gains aid in the
stability of respiratory muscles, laryngeal
and oral-pharyngeal structures important to achieve feeding milestones [e.g.,
Alexander, 1987; Larnett and Ekberg,
1995; Morris and Klein, 2000].

DEVELOPMENT OF SWALLOWING AND FEEDING

DELANEY AND ARVEDSON

Table 6. Typical Oral-Motor Development with Clinical Relevance for Transition Feeders
N; Age Groups
(months)

Source
Gesell and Ilg, 1937

N 5 10; Birth to 12
months

Gisel, 1991

N 5 143; 6, 8, 10,
12, 18, 24 months

Morris, 1982

N 5 6; Birth to 36
months

Stolovitz and Gisel,

1991

N 5 143; 6, 8, 10,
12, 18, 24 months

Wilson, 2005

N 5 48; 4, 7, 12, 35
months

Oral-Motor Development for Early

and Advanced Transitional Feeders
Growth patterns, progression of
texture advancement, and mealtime duration are factors in the feeding development of young children. Disruptions
in these factors are common in children
with feeding and swallowing problems
when they should be transitioning to
new skills that are needed to reach a
goal for table food and cup drinking.
These disruptions do not define underlying oral sensorimotor difficulties.
Understanding of the typical oral-motor
development related to feeding enables
clinicians to sort out delayed advance of
diet from disorders of feeding and swallowing. Observation and description of
oral-motor behaviors in typically developing children have been primary
means for reaching conclusions regarding oral-motor development and function. These descriptions of oral-motor
development form a basis for diagnosing
feeding disorders. Developmental hierarchies of oral-motor skill acquisition
that have been described for transitional
feeders are found primarily in reviews
and based on expert opinion through
informal observations [e.g., Bosma,
1986; Pridham, 1990; Stevenson and
Allaire, 1991; Alexander et al., 1993;
Pinder and Faherty, 1999; Morris and
Klein, 2000; Arvedson and Brodsky,
2002]. Empirically based systematic and
formal observations for typically developing transition feeders are limited
(Table 6). Formal and informal descriptions have limitations that include the
following: (1) inconsistent operational
definitions for observational normative
Dev Disabil Res Rev

Method

Normative Data

Longitudinal clinical feeding observation;

Cine recording;
No standardized feeding procedures
Cross-sectional clinical feeding observation;
Video recording of 10 trials of different
textures (puree, small piece viscous, large
piece viscous, solid).
Longitudinal clinical feeding observation;
Video recording; No standardized feeding
procedures
Cross-sectional clinical feeding observation;
Video recording of 10 trials of different
textures (puree, small piece viscous, large
piece viscous, solid)
Cross-sectional kinematic feeding
assessment, five trials of each food texture
in childs current diet.

Descriptions of oral-motor behaviors

data, (2) lack of agreement of terminology among researchers, (3) variability in

ages reported for skill acquisition, (4)
subjectivity required by observer to
interpret skills, and (5) overall limited
number of typically developing children
studied. The current state of normative
data leads to concerns regarding the
wide range of ages reported for acquisition of any specific oral skill. These
reports based on small number of typically developing children may inflate
the influence of individual variability.
The reported range of onset of oral
motor skills across typically developing
children varied from as little as 6
months to as high as 26 months for any
given skill [Morris, 1982; Carruth and
Skinner, 2002]. Descriptions of oralmotor development commonly used to
evaluate and to make management decisions for children with feeding and
swallowing deficits are based primarily
on descriptions of six children followed
over time [Morris, 1982]. The expected
age of onset for all oral-motor behaviors
was reported when two-thirds of the
participants (four of the six children)
demonstrated that particular skill.
Detailed descriptions were presented.
However, normal variability is not
likely accounted for with that limited
sample. Most descriptions of normal
oral-motor development for feeding are
based on Morris [1982].
Observation of children while
they are eating and drinking offers clinicians opportunities to note some oral
skills, but some oral movements are not
visible during these kinds of evaluations.
It is not possible to define pharyngeal,

DEVELOPMENT OF SWALLOWING AND FEEDING

Chewing duration, number of chewing

cycles, time/cycle ratios per textures
averaged across 10 trials
Descriptions of oral-motor behaviors
Frequency of occurrence of: anticipation of
food, food removal with lips, reaction
after spoon removal, tongue movements
averaged across 10 trials
Analyses:
3-dimension volume;
2-dimension horizontal excursion;
Rate/frequency of chewing.

laryngeal, and upper esophageal muscle

movements by observation. In instances
where concerns include possible pharyngeal phase swallowing problems, to
include risks for aspiration with oral
feeding, instrumental examinations
become important.
Instrumental Examinations of Oral
Sensorimotor Skills and Swallowing
Instrumental methods that supplement observations of feeding include
electromyography (EMG) and kinematic
analyses [Green et al., 1997; Wilson,
2005]. However, these methods have
limitations. For example, EMG measures muscle activation patterns but it
does not provide relevant observational
movement patterns. Kinematic analyses
yield movement patterns of the jaw in
two- and three-dimensions by tracing
reflective markers placed on the chin,
but they give no indication of bolus
position.
Other examinations that focus on
pharyngeal phase of swallowing include
videofluoroscopic swallow study (VFSS)
and flexible endoscopic evaluation of
swallowing (FEES) with sensory testing
(FEESST). VFSS provides visualization
of oral, pharyngeal, laryngeal, and upper
esophageal structures in two-dimensions. The primary focus for that examination is to define pharyngeal physiology for swallowing. The FEES with
sensory testing (FEESST) does not provide visualization of the oral phase of
swallowing, although it visualizes
tongue base, soft palate, laryngeal, and
pharyngeal structures. Details regarding
these instrumental examinations can be

DELANEY AND ARVEDSON

113

found in several sources [e.g., Willging,

1995; Willging et al., 1996; Arvedson
and Lefton-Greif, 1998; Willging and
Thompson, 2005].
Developmental Progression of
Oral-Motor and Feeding Skills
Movements of the jaw, lips, and
tongue serve as the foundation skills
required during oral feeding. The jaw
supports and positions the tongue and
lips and opens and closes to accept and
chew food [Kennedy and Kent, 1985].
The lips open to accept food, close to
contain food within the oral cavity and
may retrieve food outside the oral cavity.
The tongue curves around the food to
control it within the oral cavity, repositions and changes shape to manipulate
the bolus, retrieves food outside the oral
cavity and moves upward to contact the
hard palate to propel the bolus into the
pharynx [Kennedy and Kent, 1985;
Hiiemae and Palmer, 2003]. Overall,
early transition feeders demonstrate inaccurate and inconsistent control of oral
structures during feeding development
as they advance textures, but the oralmotor movements for feeding become
more accurate and less variable with experience, similar to experience with
other oral-motor movements [Robbins
and Klee, 1987; Clark et al., 2001].
Jaw movement development
Jaw movement development has
been the focus of considerable scrutiny
in feeding development research, likely
due to easy access during direct observation and instrumental measures. The
amount and type of jaw movement used
during feeding provides meaningful information about the motor control of
this structure. Accepted descriptions of
the developmental progression of jaw
movement from a vertical opening and
closing movement described by Bosma
[1986] eventually developing into a circular-rotary chewing pattern [Morris,
1982] may be dispelled with recent kinematic analyses of chewing development [Wilson, 2005]. More specifically,
early transition feeders are described as
using wide and ungraded jaw movements during spoon feeding. Opening
movements of the jaw to accept the
bolus are inaccurate and overshoot the
intended target, which is ascribed to
lack of experience [Morris, 1982]. Wilson
[2005] supported the descriptions of
inaccurate movements as she stated that
the 4- and 7-month old children used a
greater range of jaw movement for
pureed foods than older children and
adults. However, kinematic analyses
114

reveal that the movements of the jaw

during chewing do not follow the
predictable pattern previously described.
Kinematic analyses have expanded
understanding of the complexities of
jaw movement during feeding development that cannot be discerned by visual
inspection alone.
The initial stage of chewing development established between 6 and 9
months consists primarily of vertical jaw
movement (munching) with a suckling
motion by the tongue while chewing
solids has been agreed upon [e.g., Morris, 1982; Gisel, 1991]. The complexity
of jaw movements seems to increase
simultaneously with lateral movements
of the tongue to transfer the bolus to
the molar or chewing surfaces. These
kinematic data also suggest that overall
range of jaw movement increases as
children make advances with textures.
These findings suggest that movement
patterns are different for different textures resulting in the consensus that
children should be observed as they take
food of varying textures [Gisel, 1991;
Wilson, 2005].
The coordinative organization for
chewing measured by EMG is established by 12 months of age but continues to be refined into childhood [Green
et al., 1997]. Overall, chewing efficiency increases with age and is texture
specific. As children gain chewing efficiency, they use fewer chewing cycles
(each cycle consists of one down and
up movement of the jaw) for overall
shorter duration than when they were
first introduced to chewing [Gisel,
1988]. Chewing duration for solids significantly decreases across the transition
feeding period [Gisel, 1991] and does
not stabilize until sometime after 3 years
of age [Gisel, 1988].
Children take more time to chew
solids than pureed food, which is to be
expected since pureed foods typically
require little or no chewing. The only
gender difference occurs with girls taking more time to chew solids than boys
[Gisel, 1991]. Time/cycle ratios were
generally between 1.0 and 1.5 for all
textures and no significant differences
were found by age or texture [Gisel,
1991; Wilson 2005]. Collectively, studies suggest that infants move their jaw
with similar range of movement as
adults. Infants just learning to chew
produce the same chewing rate as adults
across textures [Wilson, 2005].
Lip movement development
Lip movement during oral feeding is readily observable. Children use

Dev Disabil Res Rev

the lips to remove food from the spoon,

to stabilize the rim of the cup to extract
liquid, and to maintain a bolus inside
the oral cavity. Poor lip strength is
thought to interfere with lip function
during feeding.
Achievement of lip closure to
remove a bolus from the spoon or to
retain a bolus within the oral cavity
varies by texture and age. Visual observation of circumoral (lip) movements
during feeding reveal differences in 6to 24-month-old childrens ability to
use full lip closure on a spoon for food
removal and to retain a bolus in the oral
cavity after removal of a spoon [Stolovitz and Gisel, 1991]. Most of the 143
children achieved lip closure on the
spoon to remove a bolus of pureed food
and maintained lip closure to retain a
bolus in the mouth. By 12 months of
age, all children achieved lip closure for
at least 80% of trials for all consistencies
for both removal and retention.
Normative midline lip closing
pressure during feeding of puree was
determined for 104 typically developing
children using a strain gauge transducer
embedded in a spoon [Chigira et al.,
1994]. The mean lip closing pressure on
the spoon steadily increased from 5
months to 3 years of age (from 25 g/
cm2 stabilizing at 75 g/cm2) while
variability decreased with age. Lip closing pressure increased only slightly
between 3 and 5 years of age [Chigira
et al., 1994]. Strength cannot be judged
accurately from clinical assessments of
oral feeding [Clark, 2003], but logical
estimations may be made from observable findings.
Tongue movement development
The tongue has important functions during oral feeding. The tongue is
highly visible when a child opens the
mouth to accept a bolus or when one
licks the lips. On the other hand, the
tongue is difficult to observe when a
child is chewing or swallowing with
closed lips. The tongue is expected to
remain in the oral cavity during feeding
except for retrieval of food from the
lips. However, early transition feeders
are likely to protrude the tongue outside of the oral cavity during feeding.
This protrusion decreases with experience. Children gradually minimize a
suckling pattern from 6 to 10 month of
age for viscous consistency and from 6
to 12 months of age for puree. As children shift to sucking patterns with the
tongue by 6 months of age, gross rolling movements in a lateral direction can
be noted. Over time, children advance

DEVELOPMENT OF SWALLOWING AND FEEDING

DELANEY AND ARVEDSON

to distinct lateral shifting of the bolus

from midline to the molar surfaces and
back to midline [Morris and Klein,
2000]. Eventually children lateralize the
bolus with the tongue from one molar
surface to the other in smooth and
coordinated movements [Alexander
et al., 1993; Morris and Klein, 2000]
with significant increase from 6 to 24
months of age for solids but not for viscous consistencies [Stolovitz and Gisel,
1991]. Only 7% of 2-year-old children
and 15% of 5-year-old children moved
a solid food from side to side precisely.
Instead, they tend to use slow and rolling tongue movements to lateralize the
food [Gisel, 1988].
Children from 12 to 36 months
of age continue to refine their oral
skills, expand the kinds of foods they
accept, become more efficient at chewing foods that require more extensive
oral manipulation, and handle liquids
via open cup. Their eating is basically
functional for regular table food with
their peers and the rest of their family.
Primary areas of oral-motor development for feeding have been
described. These skills should be considered in the general context of nutrition needs and general motor development. Oral-motor development for
feeding is described in varied sources.
However, data-based references are limited. High levels of variability are
reported in expected onset of most of
these skills but a general progression has
been established. Careful consideration
is needed when professionals use these
descriptions. More systematic normative
data are needed for adequate understanding of normal oral-motor development for feeding.
SUMMARY
Clinicians evaluating feeding and
swallowing skills of infants and young
children make their observations based
heavily on extensive knowledge of normal development, to include embryology and fetal development. Although
multiple sources contain descriptions of
oral-motor behaviors in infants and
young children, there is a need for objectivity with quantitative measures to
aid clinicians in decision making for
management of infants and children
with feeding and swallowing disorders.
Additional research findings are needed
that will assist clinicians in confirming,
expanding, or refuting observational
reports. With increased data, ages of acquisition of oral skills may be narrowed
and refined to provide the most useful
information to clinicians involved in
Dev Disabil Res Rev

evaluating infants and children with

complex feeding and swallowing issues.
Instrumental examinations of swallowing and oral skills, although discussed
only briefly, must be considered when
there are signs of possible aspiration
with oral feeding, along with possible
pharyngeal or upper esophageal swallow
deficits. Procedures and observations
may differ from one child to another,
but the ultimate goal is the same for every infant and child: a stable airway and
adequate nutrition/hydration. n

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