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
Children’s Hospital of Wisconsin-Milwaukee, University of Wisconsin-Madison, Madison, Wisconsin
2
Children’s Hospital of Wisconsin-Milwaukee, Medical College of Wisconsin-Milwaukee, Milwaukee, Wisconsin
The development of feeding and swallowing involves a highly com-
plex 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 nor-
mally 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 neurophysiol-
ogy 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 profes-
sionals to appreciate differences from normal in infants and children with
feeding and swallowing disorders. Additional research of infants and chil-
dren who demonstrate overall typical development in oral skills for feed-
ing is encouraged and will provide helpful reference points in increasing
understanding of children who exhibit differences from typical develop-
ment. 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 com-
prehensive review of factors influencing oral intake, growth, nutrition,
and neurodevelopmental status of children. ' 2008 Wiley-Liss, Inc.
Dev Disabil Res Rev 2008;14:105–117.
Key Words: infant; child; development; feeding; swallowing; sucking;
neurobiology
DEVELOPMENT OF SWALLOWING AND
FEEDING: PRENATAL THROUGH FIRST
YEAR OF LIFE
A
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 typ-
ically 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 2–3 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 develop-
mental anatomy of the upper aerodigestive tract and the nor-
mal physiology of deglutition [e.g., Miller, 1982, 1999; Arved-
son and Brodsky, 2002]. Research in recent years has added to
the understanding of the development of feeding and swallow-
ing 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, Children’s 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

4–5 Endoderm of yolk sac incorporated into embryo to
form primordial gut
4 Mandible via 1st branchial arch
6 Oropharyngeal membrane ruptures to form
primitive choanae allowing for nasal breathing
6–7 Separation of esophagus and trachea from the
primitive foregut
Basis for separate esophagus and trachea
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 activ-
ities 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 com-
munication (unique to humans) is mul-
tifactorial 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 neurophysiol-
ogy 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 de-
velopment of sucking, swallowing, and
breathing coordination that is an impor-
tant underpinning for oral feeding in
preterm and term infants; (2) develop-
mental 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 devel-
oping 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 tex-
tures [e.g., Rogers and Arvedson,
2005]. The critical need for understand-
ing the anatomy of the oral/pharyn-
geal/laryngeal/esophageal mechanism
106
and the physiology of deglutition can-
not be overstated, although that is not a
major focus for this review. Pediatric
specialists working with infants and
children with diverse feeding and swal-
lowing problems must keep develop-
mental milestones of typically develop-
ing 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 develop-
mental changes in the embryonic (first
8 weeks of gestation) and fetal (week 9
to birth) periods. The neurodevelop-
mental maturation of cerebral and
brainstem pathways involved in swal-
lowing 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 prena-
tal 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 post-
menstrual 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  DEVELOPMENT OF SWALLOWING AND FEEDING
(28–31 days) or lunar months (28 days)
are meant. However, it is more com-
mon for these ages to be described in
months.
Relevant Embryologic and Fetal
Development
Embryonic period (weeks 1–8)
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 fer-
tilization of the ovum and continue af-
ter birth. The beginnings of most essen-
tial 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 pe-
riod 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 Pre-
saud, 2003]. During this period, the fe-
tus undergoes dramatic development of
swallowing, sucking, and oral sensori-
motor function. The oral cavity, phar-
ynx, and esophagus are three distinct
anatomic regions that can function sep-
arately but, in swallowing, they inte-
grate their functions via a neuronal net-
work. 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
 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 18–24 weeks gestation. Roots of a
number of cranial nerves (CN) are my-
elinated during 20–24 weeks gestation:
III (oculomotor), IV (trochlear), VI
(abducens), as well as the intramedullary
roots of cranial nerves VII (facial), IX
(glossopharyngeal), and XII (hypo-
glossal). These changes correspond with
the appearance of opening and closing
of the jaw, anterior tongue movements,
and suckling seen on ultrasound imag-
ing after 18 weeks gestation [Miller
et al., 2003].
Peak synaptogenesis of the me-
dulla is seen at 34–36 weeks gestation.
By 35–38 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 cen-
ters 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 stereog-
nosis, vibrotactile detection, proprio-
ception, nociception, and chemical and
thermal sensitivity. Detailed descriptions
of each modality with its neural inner-
vation and function can be found in
Miller [1999 pp 13–33]. A variety of
sensory attributes are integral to oral-
motor function to prepare liquid and
food for swallowing.
Taste is one of the most complex
sensations evoked from the oral-pharyn-
geal 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  DEVELOPMENT OF SWALLOWING AND FEEDING
temperature, and the chemical sense of
taste [Linden, 1993]. Taste and tactile
sensation in oral regions is well devel-
oped in fetal rats and sheep [Mistretta,
1972; Bradley and Mistretta, 1973].
Sensory fibers responding to taste syn-
apse in the rostral nucleus tractus soli-
tarius (NTS). Taste buds develop during
weeks 11–13 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 tri-
geminal 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]. Gus-
tatory neurons are organized topograph-
ically. The majority of the NTS inter-
neurons discharge to stimulation of taste
buds in specific regions.
The oral, pharyngeal, and esopha-
geal 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 unmyeli-
nated 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]. Like-
wise, 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 stim-
uli with the tongue having a high den-
sity 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
(C1–C3) nerves. Central pattern genera-
tors in specific regions of the brain stem
appear to control movements of mastica-
tion, 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
 DELANEY AND ARVEDSON
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]. Swal-
lowing can be evoked by multiple cen-
tral 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 res-
piration and swallowing.
The relationship between the tim-
ing of respiration and swallowing has
been studied via transynatic neural trac-
ers (cholera toxin horseradish peroxidase
[CT-HRP] and pseudorabies virus
[PRV]) that effectively label afferent ter-
minal fields within the nucleus of the
solitary tract (NTS) as well as swallow-
ing 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 motoneur-
ons with premotor neurons located in
the area of NA. Motoneurons that in-
nervate all levels of the esophagus are
confined to the compact formation
(NAc). While the motoneurons projec-
ting 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 gen-
eration 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 pha-
ryngeal motoneurons and buccophar-
yngeal PMNs and is synaptically linked
to esophageal peripheral motor neurons
(PMNs). This link between buccophar-
yngeal and esophageal PMNs provides a
potential anatomic substrate within the
NTS for the central integration of
esophageal peristalsis with the pharyn-
geal phase of swallowing and airway-
protective reflexes. Both human studies
and animal models that investigate
107
esophagoglottal closure and pharyngo-
upper esophageal sphincter (pharyngo-
UES) 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 oropha-
ryngeal sensory input to adults has been
shown to impede cortical control for
swallowing through magnetoencepha-
lography (MEG) [Teismann et al.,
2007]. Teismann et al. found decreased
motor activation apart from a strongly
reduced sensory representation. Signifi-
cantly 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 devel-
oping brain.
Sensory input for infants. Breathing, suck-
ing, and swallowing activities occur in
the upper aerodigestive tract and are
orchestrated by specific areas in the
CNS. When pharyngeal and laryngotra-
cheal sensation is reduced, aspiration is
likely to occur with no overt manifesta-
tions, 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]. Predomi-
nant responses of sleeping infants stimu-
lated by introduction of a small bolus
(0.1 ml) of water or saline into the
pharynx via a nasal catheter are swal-
lowing, 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 stimu-
lated by fluid contacting the mucosa of
the larynx. These reflexes are initiated
in the fetus and newborn when hypo-
chloremic or strongly acidic solutions
contact the epithelium that surrounds
the entrance to the laryngeal airway
108 Dev Disabil Res Rev
[Thach, 2001]. The LCRs include star-
tle, rapid swallowing, apnea, laryngeal
constriction, hypertension, and brady-
cardia. 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 laryn-
geal 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 pro-
nounced, 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]. Clini-
cians 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, par-
ticularly outcomes data on infants who
continue to feed orally.
Prenatal Sucking, Swallowing,
and Breathing
Ultrasound studies of fetuses have
revealed early development of swallow-
ing and oral sensorimotor function
[e.g., Ross and Nyland, 1998; Miller
et al., 2003]. Fetal swallowing is impor-
tant for the regulation of amniotic fluid
volume and composition, recirculation
of solutes from the fetal environment,
and maturation of the fetal gastrointesti-
nal 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 swal-
lowing it. A suckling response may be
elicited at this stage as reported in spon-
taneously aborted fetuses [Moore and
Persaud, 2003]. Forward tongue thrust-
ing has been reported by 21 weeks ges-
tation, tongue cupping at 28 weeks ges-
tation, and suckling (anterior-posterior
tongue movements) between 18 and 24
weeks gestation. Self oral-facial stimula-
tion is shown to precede suckling and
swallowing [Miller et al., 2003]. Con-
sistent swallowing is seen by 22–24
weeks gestation [Miller et al., 2003].
The near term fetus swallows amniotic
 DEVELOPMENT OF SWALLOWING AND FEEDING
fluid at a volume of about 500–1,000
ml/day [Ross and Nyland, 1998].
Substantial weight gain occurs
from 21 to 25 weeks. By 24 weeks, sur-
factant 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 (viabil-
ity is defined as the ability of a fetus to
survive in the extrauterine environ-
ment).
By 26–29 weeks, the lungs are ca-
pable 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 26–28
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) dem-
onstrated statistically similar patterns of
general physical growth, but significant
differences were found in development
of specific lingual and pharyngeal struc-
tures, laryngeal and pharyngeal motor
activity, and oral-lingual movements.
Complex oral-motor and upper airway
skills emerged earlier in females, sug-
gesting a sex-specific trajectory of
motor development [Miller et al.,
2006]. Pharyngeal and laryngeal move-
ments in males were less rhythmic and
complete than in females throughout
the second trimester. By the third tri-
mester, these movements became more
similar. Overall, females attained oral-
motor 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 disorgani-
zation of sucking, swallowing, and
 DELANEY AND ARVEDSON
 aroused or agitated on the other hand,
Table 2. Infant Readiness for Oral Feeding on Basis of feedings do not typically go smoothly
Behavioral Organization States and easily because the behaviors inter-
fere with suck, swallow, and breathe
State Behavioral Organization State Related to Feeding Readiness sequencing.
1 Deep sleep, seldom seen in a preterm infant Non-nutritive sucking (NNS)
2 Light sleep success is commonly used as one of the
3a Drowsy markers of readiness for an infant to
4a Quiet awake and/or alert feed by bottle [Pinelli and Symington,
5a Actively awake and aroused
6 Highly aroused, agitated, upset and/or crying
2001], although only a few studies have
examined the relationships between the
a
Behavioral organization states optimal for oral feeding. Adapted from Als, 1985, 1986; Brazelton and Nugent, 1995. characteristics of NNS and nutritive
sucking (NS). Most infants are given
NNS experiences via pacifier. Studies
have demonstrated positive effects of NNS
breathing coordination for the first cou- tle-fed. The survival rates of preterm via pacifier in multiple ways (Table 3).
ple weeks of life. The course toward infants have improved significantly in Fucile et al. [2002] reported that their
oral feeding is different in preterm recent years, but one of the most com- experimental group of preterm infants
infants delivered at shorter gestation. mon and urgent care issue that contin- reached independent oral feeding 1
ues, is the subject of when and how to week earlier than a sham group with no
Preterm infant feeding development initiate and to advance oral feedings. intervention when specific stimulation
The first concerns following pre- The ability to make a transition from of oral structures was carried out for 15
term delivery relate to stabilization of gavage to oral feeding depends on neu- min once per day for 10 days starting
respiration to support life. Infants with- rodevelopmental status related to behav- 48 hr after discontinuation of CPAP.
out major cardiorespiratory or GI tract ioral organization (Table 2), to cardio- However, there was no difference in
deficits are appropriate for introduction respiratory regulation, and to the ability length of stay between the two groups.
to non-nutritive sucking, usually via to produce a rhythmic suck-swallow- Similarly, Bragelien et al. [2008] re-
pacifier, as early as 28–29 weeks PCA. breathe pattern. Healthy term infants ported that a stimulation program did
Some infants who are intubated orally have that ability, but preterm infants less not result in earlier weaning from NG
are noted on ulstrasound to suck on the than 32 weeks PCA are neurologically tube feedings in premature infants or
tube, likely a continuation of sucking immature and rarely they are capable of earlier discharge when compared to
that is noted in utero as the fetus can be that coordination. Preterm infants can similar infants with no intervention. It
seen to suck fingers or suck on the become stressed with bottle feeding for would be of interest to have a compari-
tongue. several reasons to include, but not lim- son group receiving some other type of
ited to, (1) neurological immaturity, (2) ‘‘hands on’’ intervention, e.g., soothing
Non-nutritive sucking: Indicator of oral difficulty regulating autonomic func- touch to other body parts with a ques-
feeding readiness in preterm infants tions, and (3) difficulty achieving be- tion of potential for facilitating oral
One of the most complicated havioral state organization when they feeding. This comparison has been
tasks required of a newborn infant is are presented with stimuli [Als and shown for reducing pain during heel
oral feeding that involves complex inte- Brazelton, 1981; Brazelton and Nugent, stick with saturation levels maintained
gration of anatomic structures to 1995]. Oral feeding is usually optimal significantly better in Yakson (a tradi-
include lips, jaw, cheeks, tongue, palate, when an infant is drowsy, in a quiet tional Korean touching method) and
pharynx, and larynx. Coordinated awake and alert state, or actively awake NNS group compared to control group
rhythmic sequences of sucking, swal- and aroused. When an infant is in deep neonates [Im et al., 2008]. These
lowing, and breathing are required of sleep (seldom seen in preterm infants) authors found no difference among the
infants whether they are breast- or bot- or in light sleep, on one hand, or highly groups with regard to heart rate and

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

Paludetto et al., 1984 Increased transcutaneous oxygen tension between 32 and 35 weeks gestation
Burroughs et al., 1978 Promoting oxygenation
Treloar, 1994 Higher transcutaneous oxygen tensions [tcPO2s] after crying induced by heelstick
Field and Goldson, 1984; South et al., 2005; Im et al., Soothing during invasive procedures (less fussing and crying); Pain reduction during heel
2008 stick procedure
Field et al., 1982; Gaebler and Hanzlik, 1996 Shorter transition from tube to oral feeding; shorter hospital stay
Bernbaum et al., 1983 Maturing suck pattern, enhanced growth and maturation
Measel and Anderson, 1979 Improved digestion by simulating the natural way nutrients are ingested
Field et al., 1982 Weight gain
DiPietro et al., 1994; McCain, 1995 Regulating state and facilitating optimal behavioral state for feeding
Standley, 2003 NNS with music significantly increased feeding rate
Pickler and Reyna, 2004 Prefeeding NNS had no effect on NS, breathing during feeding, or select behavioral
characteristics of feeding

Dev Disabil Res Rev  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 displace-
ments and excursions when a preterm
infant was sucking for nutritive pur-
poses (NS) compared to NNS on a pac-
ifier. The angle of the hyoid movement
was significantly greater with NS than
with NNS. Vertical tongue body excur-
sions occurred similar to those previ-
ously considered at 6–9 month develop-
mental skill levels. These authors sug-
gested that technical advances in
noninvasive ultrasound imaging techni-
ques with integration of semiautomatic
computerized analyses of tongue surface
configurations and hyoid activity pro-
vide 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 matu-
ration 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 regula-
tion [McCain, 2003]. Some infants do
appear ready to begin oral feeding at
32–33 weeks gestation [Cagan, 1995;
McCain, 2003], although 34 weeks ges-
tation is often used as the lower limit of
expectations for full oral intake to meet
nutrition and hydration needs.
Developmental patterns of rhyth-
mic 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 Dev Disabil Res Rev
sucking is irregular with an average of
2–3 sucks per sec and not linked with
swallowing. Transitions occur during
week 34. From 35 to 40 weeks’ PMA,
infants have well-defined sucks occur-
ring at 1 suck per sec and suck/swallow
sequences appear well established. The
ratio of 1 suck to 1 swallow predomi-
nates in infants until they are beyond 40
weeks PMA. At that age it is not un-
usual for 2–3 sucks per swallow to
occur [Qureshi et al., 2002]. These
changes may reflect a pattern of matura-
tion representing the process of enceph-
alization 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 achieve-
ment of full bottle feedings may be
facilitated by increased bottle-feeding
opportunities, given the inverse rela-
tionship found via number of bottle
feedings received per day during transi-
tion 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 feed-
ings 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 incom-
plete descriptions of methodology in
some studies. They concluded that
overall findings support cautious con-
tention 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 insuffi-
cient 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
 DEVELOPMENT OF SWALLOWING AND FEEDING
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 ven-
tilation, respiratory rate, and tidal vol-
ume 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 expira-
tion [Kelly et al., 2007].
The anatomy of oral and pharyn-
geal structures in the first few months
of life underlies and facilitates nipple
feeding. The mandible is disproportion-
ately small compared to the skull. The
tongue fills the oral cavity and contacts
all surfaces leaving little space for varia-
tion 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 one-
third 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 separat-
ing 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 liq-
uid into the lungs. This anatomic con-
figuration supports the act of suckling,
defined as backward–forward 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 Acad-
emy 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 7–8 feedings
lasting 15–20 min at 2–3 hr intervals.
Typical infants increase the amount of
breast milk or formula by 30 ml (1 oz)
per month until 6–9 months when they
take 240 ml (8 oz) per feeding 3–4
times per day [Samour and King, 2006]
(Table 4). By 6 months of age, these
infants taking smooth pureed food by
 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 7–8 2–4 ounces (60–120 ml)
1–3 5–7 4–6 ounces (120–180 ml)
3–6 4–5 6–7 ounces (180–210 ml)
6–9 3–4 7–8 ounces (210–240 ml)
9–12 3 7–8 ounces (210–240 ml)
Adapted from Samour and King, 2006.
spoon are still getting 80% of nutrition language skills) are below chronologic
needs met by formula or breast milk age (or adjusted age for children born
with decrease to 50% by 10 months of prematurely), feeding and swallowing
age [e.g., Samour and King, 2006]. Effi- specialists should guide parents and
cient infants and children spend 30 min other professionals in ways that help
or less at mealtimes [Reau et al., 1996]. them to appreciate fully the relationship
The AAP Committee on Nutri- of oral feeding skills and global develop-
tion recommends that infants are given mental levels. For example, a child at 12
iron-fortified formula or breast milk months chronologic age, 9 months
until 12 months of age for optimal adjusted age (born at 26 weeks gesta-
nutrition status [AAP, 1999]. Cow’s tion) and not yet sitting independently
milk before 12 months of age increases (expected by 6 months), is not expected
the risk for iron deficiency anemia, to chew and swallow solid food. This
milk protein allergy, gastrointestinal child realistically would be expected to
blood loss, and inadequate nutrition. have oral feeding and swallowing skills
No nutrition supplement is equivalent to a typically developing
required until 6 months of age as term infant at about 6 months of age. At that
infants usually have adequate iron stores age, nipple feeding continues to be the
until then, whether they are breast or primary means of meeting nutrition and
bottle fed [Griffin and Abrams, 2001; hydration needs with spoon feeding for
Samour and King, 2006]. By 6 months practice and developmental skill
of age, caloric requirements are not advancement. In addition to the skill de-
always satisfied with formula or breast velopment that infants experience dur-
milk alone. Total breast-fed infants ing the first year of life, they also partici-
require iron and zinc supplements, usu- pate in reciprocal feeding or mealtime
ally by introduction of iron-fortified relationships that change over time.
infant cereal and pureed meats by spoon
[Fomon, 2001; Samour and King, 2006;
Krebs, 2006]. The transition to spoon Relationship changes relevant to feeding
feeding is an important milestone for development
developmental skill purposes and nutri- Feeding during infancy is a recip-
tion well-being. rocal process that depends on specific
abilities and characteristics of caregivers
and infants with a give-and-take
Preterm infant age adjustments after birth exchange. Normal feeding development
Preterm infants should be given includes the following three stages: ho-
the benefit of their adjusted ages for the meostasis (0–2 months), attachment
first 24 months of life. In addition, (3–6 months), and separation/individua-
functional levels relating to gross and tion (6–36 months) [Chatoor et al.,
fine motor skills, cognitive skills, and 1984]. A healthy positive feeding rela-
language and speech skills, must all be tionship is critical for successful feeding.
taken into account when determining Caregivers need to understand the pro-
expectations for oral feeding recom- cess in the young infant’s achievement
mendations. The expectations for feed- of some degree of self-regulation during
ing skills and swallowing safety are esti- the stage of homeostasis. Caregivers
mated in relation to both adjusted age must recognize and respond promptly to
and overall developmental status. Differ- hunger cues, and they should assist the
ences become particularly important infant in regaining an organized state af-
when determining readiness for advanc- ter becoming overstimulated or upset.
ing textures. When overall developmen- During the stage of attachment, infants
tal skill levels (gross and fine motor begin to engage interest of other people
skills as well as cognitive and speech/ in interactional patterns [Greenspan and
Dev Disabil Res Rev  DEVELOPMENT OF SWALLOWING AND FEEDING  DELANEY AND ARVEDSON
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 pri-
mary behavioral development is a strug-
gle 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 impor-
tance of swallowing efficiently without
risks for aspiration, successful feeding
also requires appropriate reciprocal rela-
tionships 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 regard-
ing optimal facilitation of safe and non-
stressful feeding. The need for knowl-
edge 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: Transi-
tion feeding. Infants demonstrate readi-
ness 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 lower-
ing 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 oral-
pharyngeal complex occurs as the pos-
terior 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 introduc-
tion of spoon feeding. Sucking is char-
acterized by the tongue showing verti-
cal movement to extract liquid with
only small vertical movement of the jaw
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 [Illing-
worth 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 spe-
cific oral movements if these new tex-
tures 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 Beau-
champ, 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 vege-
tables. However, multiple exposures to
varied foods increased their overall ac-
ceptance 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 lim-
ited experiences with multiple flavors
for infants on milk based formulas
[Mennella et al., 2004].
112 Dev Disabil Res Rev
Table 5. Selected Motor Skills (Gross, Fine, and Oral) in
Children During Transition Feeding Development
Mean age (months)
4–5
6–8
8–10
10–12
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 mandib-
ular incisors (6–8 to 12–13 months),
molars (12–24 months), and canines
(16–20 months) [Bosma, 1986; Arved-
son and Brodsky, 2002].
Introduction of spoon feeding
The introduction of spoon feed-
ing of thin smooth pureed food occurs
once a child reaches about a 6-month
level developmentally. Foods are intro-
duced 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 ingre-
dient foods have been offered usually
between 7 and 9 months of age. Gradu-
ally food with texture are added, such
as, dissolvable solids (e.g., soft cracker at
 DEVELOPMENT OF SWALLOWING AND FEEDING
Motor Skill
Sit on caregiver’s 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
6–9 months), textured puree foods
(e.g., mashed banana, cottage cheese at
6–9 months), ground solids at 6–9
months, soft diced solids (e.g., fruits and
vegetables at 9–12 months), and eventu-
ally a general toddler diet of table foods
by 12–18 months of age.
In the U.S. and some other coun-
tries, a spout cup is introduced between
6 and 9 months as a beginning step in
weaning from the breast or bottle. Chil-
dren 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 birth-
day. Independent drinking from an
open cup usually occurs later.
With these feeding transitions, gen-
eral motor development and oral feed-
ing 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 self-
feeding activities These gains aid in the
stability of respiratory muscles, laryngeal
and oral-pharyngeal structures impor-
tant to achieve feeding milestones [e.g.,
Alexander, 1987; Larnett and Ekberg,
1995; Morris and Klein, 2000].
 DELANEY AND ARVEDSON
 Table 6. Typical Oral-Motor Development with Clinical Relevance for Transition Feeders
N; Age Groups
Source (months)
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, N 5 143; 6, 8, 10,
1991 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 du-
ration are factors in the feeding devel-
opment 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 under-
lying 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 swal-
lowing. Observation and description of
oral-motor behaviors in typically devel-
oping children have been primary
means for reaching conclusions regard-
ing oral-motor development and func-
tion. These descriptions of oral-motor
development form a basis for diagnosing
feeding disorders. Developmental hier-
archies 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 devel-
oping transition feeders are limited
(Table 6). Formal and informal descrip-
tions have limitations that include the
following: (1) inconsistent operational
definitions for observational normative
Dev Disabil Res Rev  DEVELOPMENT OF SWALLOWING AND FEEDING
Method
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 child’s current diet.
data, (2) lack of agreement of terminol-
ogy 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 acquisi-
tion of any specific oral skill. These
reports based on small number of typi-
cally 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 oral-
motor development commonly used to
evaluate and to make management deci-
sions 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 clini-
cians 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,
 DELANEY AND ARVEDSON
Normative Data
Descriptions of oral-motor behaviors
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 pha-
ryngeal 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 supple-
ment observations of feeding include
electromyography (EMG) and kinematic
analyses [Green et al., 1997; Wilson,
2005]. However, these methods have
limitations. For example, EMG meas-
ures 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-dimen-
sions. The primary focus for that exam-
ination is to define pharyngeal physiol-
ogy for swallowing. The FEES with
sensory testing (FEESST) does not pro-
vide 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
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, reposi-
tions 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 in-
accurate and inconsistent control of oral
structures during feeding development
as they advance textures, but the oral-
motor movements for feeding become
more accurate and less variable with ex-
perience, 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 obser-
vation and instrumental measures. The
amount and type of jaw movement used
during feeding provides meaningful in-
formation 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 cir-
cular-rotary chewing pattern [Morris,
1982] may be dispelled with recent ki-
nematic analyses of chewing develop-
ment [Wilson, 2005]. More specifically,
early transition feeders are described as
using wide and ungraded jaw move-
ments 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 Dev Disabil Res Rev
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 develop-
ment that cannot be discerned by visual
inspection alone.
The initial stage of chewing de-
velopment 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., Mor-
ris, 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 tex-
tures 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 estab-
lished by 12 months of age but contin-
ues to be refined into childhood [Green
et al., 1997]. Overall, chewing effi-
ciency increases with age and is texture
specific. As children gain chewing effi-
ciency, 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 sig-
nificantly 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 tak-
ing 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, stud-
ies 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 feed-
ing is readily observable. Children use
 DEVELOPMENT OF SWALLOWING AND FEEDING
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 obser-
vation of circumoral (lip) movements
during feeding reveal differences in 6-
to 24-month-old children’s 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 [Stolo-
vitz 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 clos-
ing 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 observ-
able findings.
Tongue movement development
The tongue has important func-
tions 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 out-
side of the oral cavity during feeding.
This protrusion decreases with experi-
ence. 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 chil-
dren shift to sucking patterns with the
tongue by 6 months of age, gross roll-
ing movements in a lateral direction can
be noted. Over time, children advance
 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 vis-
cous 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 roll-
ing 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 chew-
ing 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 de-
velopment for feeding have been
described. These skills should be con-
sidered in the general context of nutri-
tion needs and general motor develop-
ment. Oral-motor development for
feeding is described in varied sources.
However, data-based references are lim-
ited. 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 under-
standing of normal oral-motor develop-
ment for feeding.
SUMMARY
Clinicians evaluating feeding and
swallowing skills of infants and young
children make their observations based
heavily on extensive knowledge of nor-
mal development, to include embryol-
ogy and fetal development. Although
multiple sources contain descriptions of
oral-motor behaviors in infants and
young children, there is a need for ob-
jectivity 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 ac-
quisition of oral skills may be narrowed
and refined to provide the most useful
information to clinicians involved in
Dev Disabil Res Rev  DEVELOPMENT OF SWALLOWING AND FEEDING
evaluating infants and children with
complex feeding and swallowing issues.
Instrumental examinations of swallow-
ing 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 ev-
ery infant and child: a stable airway and
adequate nutrition/hydration. n
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