NIGHAT TAHIR

SENIOR LECTURER
OCCUPATIONAL THERAPY DEPARTMENT
IPMR,DUHS,KARACHI.

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GETTING TO KNOW YOU…

WHAT DO YOU KNOW ABOUT

FEEDING AND EATING?

WHAT YOU WANT TO KNOW?

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 PURPOSE

 To help students
 Identify problems in feeding/oral
development as early as possible
 Implement current, evidence-based
feeding interventions

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DEFINITIONS

 Feeding is the term used to describe “the process of setting up, arranging,
and bringing food [or fluid] from the plate or cup to the mouth;
sometimes called self-feeding” (AOTA, 2006a).

 Eating is defined as “the ability to keep and manipulate food or fluid in

the mouth and swallow it; eating and swallowing are often used
interchangeably” (AOTA, 2006a).

 Swallowing involves a complicated act in which food, fluid, medication,

or saliva is moved from the mouth through the pharynx and esophagus
into the stomach (AOTA, 2006a).

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 • Drooling (or dribbling) is the unintentional loss of saliva from the
mouth. In cerebral palsy, drooling is usually related to:
• • abnormalities in swallowing (rather than an absence of
swallowing) • difficulties moving saliva to the back of the throat
• poor mouth closure • jaw instability • tongue thrusting
 Dysphagia. refers to any difficulties which may occur in the oral,
pharyngeal or esophageal stage of the swallow, including any difficulty
in the passage of food, liquid or medicine during any stage of
swallowing that impairs the client’s ability to swallow independently
or safely (AOTA, 2007).

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 PRIORITIES OF BODY DURING EATING

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 • First priority
Breathing is the body’s number. Without good
oxygenation, eating becomes very difficult. We shut off our
airway briefly with every swallow and our oxygen level
decreases slightly (or we have to significantly increase our
respiratory rate to maintain oxygen such that we are burning
off any calories we take in.
• Second priority
Postural stability is our bodies’ second priority If either
breathing or postural stability are compromised, eating may
be resisted.

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 Positioning
and
handling
Use key intervention
points to Encourage
inhibit and symmetrical
facilitate body
tone position
Occupational
Therapy
Intervention
Promote
Work on hand function
milestone of the
affected side
Train in
activities of
daily living

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 Feeding
Normally during the first few months ,a baby takes food in by what
is known as a sucking –swallowing reflex. As this reflex is
insufficient in some CP from birth meal times present real
difficulties for him

a) Distribution of normal reflex

 Rooting
 Suckle
 Swallow
 Gag
 Cough

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 b) Pathological reflex
c) The link between hand and mouth
d) Oral sensation
e) Failure to chew
f) Poor lip activity
g) Pattern of movement (jaw ,lips, tongue, swallow, breathing and
vocalization)

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 Feeding Disorder
 “Feeding problems in childhood typically have a
neurodevelopmental origin and reflect a spectrum
of delays and disabilities”
(Rogers, B. , Neurodevelopmental Aspects of Feeding Disorders,
Seminar for Feeding Teams, 2002)

 Problems gathering food in the mouth and

sucking, chewing, or swallowing for appropriate
intake

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KEY CONTROL
We can not go through individual treatment of above problems, but can
use key aspects of the treatment.

 Positioning

 Jaw Control

 Normalizing Oral Sensation

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 ORAL STRUCTURE
The size, shape, and position of the jaw, lips,
cheeks, tongue, teeth, palate, pharynx,
hyoid, and vocal tract that is unique to the
individual

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Lip control
Hypertonia /Hypotonia in the cheeks reduces the
strength/skill of the lips causing inefficient sucking and bolus
collection, excessive drooling and open mouth/partial open
mouth.
Lip retraction

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TONGUE PATTERN

Normal tongue pattern Abnormal tongue pattern

Tongue movement is integral
part in eating process.There are
6 pattern of tongue movement.
1) Suckle
2) Simple tongue protrusion
3) Sucking
4) Munching
5) Tongue tip elevation
6) Lateral tongue movement
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1) Tongue thrust
2) Tongue retraction
3) Exagerated tongue
protrusion
4) Asymmetrical tongue
placement
Abnormal tongue pattern

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Jaw pattern

Normal jaw pattern Abnormal jaw pattern

• Up and down movement • Tonic bite jaw thrust
• Munching • Jaw thrust
• Angle /lateral movement • Jaw retraction
of jaw
• Diagonal rotary
movement
• Circular rotary

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 Oral Sensorimotor Functioning

“The integration of an individual’s oral anatomy with

their sensory and motor systems for the support of
eating, drinking, swallowing, speaking, and
performance of non-speech oral movements including
maintaining appropriate oral resting postures all within
a foundation of positive learning experiences”
Nancy Sinden, 2010

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 SENSORY ORAL MOTOR
TREATMENT PROTOCOL

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 Mealtime
Partnership

Nutritional Fear & Trust

Challenges

Mealtime Skills

Sensory
Comfort &
Experience Gastrointestinal
Oral-Motor
Comfort &
Coordination Experience

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Physical
Coordination
 Fear or Trust also includes

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Relationship Between Physical
Positioning and Sensory Information

When the muscle tone and

movement in a child’s
body is more normal, there Hyper-reaction to the
is usually less of a problem touch of the spoon in the
with sensory information. mouth often causes a child
The child may be less to bite down and have
distractible, or less over trouble letting go. There
stimulated with excitement will be less biting if the
or head is in the middle and if
anticipation of the meal. it is not pushing back. When
the head is too far forward,
or too far back, this bite
reflex is usually stronger.

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 Oral Intervention…

Beckman Oral Motor Protocol

Oral aversion: Gum Massage

Jaw stability and strength

Tongue Control

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 Seating and Positioning
 Head, neck, and body aligned, Check
positioning of the hips/shoulders/chin
(reduce hip extension or posterior tilt
and shoulder retraction, and position
the chin down)
 Ear at least slightly above mouth during
bottle-feeding (45 degree angle +)
 Body in a correct cradle, side-lying, or
football hold during nursing

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 POSITION DON’T
1
If head is tilted back and Push or force the head forward
the neck stretched with your hand: this will only
increase the tendency to push
back.
DO’S
Seating the child in your lap
or seat Support the head in
crook of one arm. Make
sure legs are bent it will
help to prevent slip off.

2
Steady the head by lacing
your hand on the neck at the
base of the head

Place a small cushion or

rolled towel in the nape of
the neck
3
If head mainly flexed with Try to force the head back by support the head by
the head pushed down on pushing under the chin or feed placing a hand on the neck
to the chest. whilst the head lies in a just under the chin or base
forward or sideways position of head .

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 Lip Exercises

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 Lip Exercises
• Increase tone in body with bouncing and
compressions
• Lip massage: rub infadent finger or roll cut
down toothette from the R corner to midline, the
L corner to midline *DO NOT CROSS
MIDLINE
• Licking honey from the roof of the mouth or
behind the top front teeth improves tongue
elevation/lifting.
• Reduce hyper tonicity in cheeks with vibrating
hands on each cheek forward or vibrating
bug/Z-vibeLip massage:
• Reduce hypertonicity by rub lips from midline
out ward to sides (stretch)

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 Tongue Retraction
• To increase tongue
movement and coordination.
 Work on building tone by
bouncing on a ball or lap
before positioning for
eating
 Stroke tongue from
middle to tip toward lips

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 Tongue Protrusion

 Offer vibration with battery operated

toothbrush or Z-Vibe
 Position in feeding chair with increased
support of the trunk and feet
 Feed to the sides of the mouth to
improve tongue lateralization

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 JAW EXERCICES
• If jaw very stiff encourage sequencing of opening and closing
the jaw by putting hand firmly under the chin.
• Icing is best to relax the muscles.
• Vibrator at end ear lobe or tapping .
• Practice of chew/bite chewy or chewy sticks minimum 5-20
times.

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 Jaw Stability and strength

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TECHNIQUES TO CONTROL DROOLING
(LIPS, JAW TONGUE AND CHEEKS)

 Give jaw control/support as needed

 Calm/organize the mouth with vibration
 Icing around the lips half direction from
right to left and then left to right (cold
increases swallow reflex )
 Chew tubes
 Bite tip on Z-Vibe (front to back on left
and right)
 Do not wipe the mouth horizontally with a tissue
under the lower lips as it often promote more
production of saliva.

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 Sensory Needs
How comfortable is the child in his/her feeding environment

 Change the noise, lighting and visual stimuli

 Prepare the body and mouth for eating (PRR/brushing,
swinging, proprioception, vibration, massage)
 Changing food (temp, taste, texture) slowly
 Hyposensitivity (ASD, low tone) prefer to drink and not eat or
prefer to eat soft/easy foods. *add spice to their life
 Hypersensitivity (CP, high tone) use smooth bland food
 Be social and engaging during meal times.

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 Systematic desensitization
Increasing a child's comfort level:
● Texture
● Taste
● Smell
● Consistency
Showing children that eating does not have to be:
● Scary
● 2-step process into the mouth, but rather multiple steps
exploring and building a positive relationship with food.

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 Specific Strategies/utensils to Promote Eating
and Drinking

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12/31/2021 Fist OT National Conference Workshop: ORAL MOTOR
TECHNIQUES FOR CP CHILDREN NIGHAT TAHIR
Modified Bottles Flat Firm Spoon Lip Closure Spoon

• ● Straight, long and • ○ Easy for lips to • Encourages lip

firm nipples ● clear the bolus ○ spread and
Pliability of bottle Firmness for closure ○ Border
allows assistive providing pressure cues the lip to
squeeze to increase on the tongue ○ come down
flow ● One- way Encourage cupping
valve decreases air ○ Lateral
intake placement of puree
○

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Textured spoon VIBRATING SPOON
• Improve tolerance of • Improve awareness
texture in the mouth • Increase muscle tone
• Improve awareness
and stabilization

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 TAKING BITES AND CHEWING
FOODS
 Baby bite-sized food pieces in
safe feeder or cheesecloth
 Move from front of mouth to
back molar area as baby bites
 12 to 15 chews on one side then
the other at back molar area

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References
• Miller, A. J. (1999). The neuroscientific principles of
swallowing and dysphagia. San Diego, CA: Singular
Publishing Group, Inc. Mirret, P.L., Riski, J.E., Glascott,
J., & Johnson, V. (1994). Videofluoroscopic Assessment of
Dysphagia in Children with Severe Spastic Cerebral
Palsy.Dysphagia,.9, 174-179. Morris, S.E. (1989)
Development of Oral-motor skills in the Neurologically
Impaired Child Receiving non-Oral Feedings. Dysphagia.
3,135-154. Morris, S.E., & Klein, M.D. (2000). Pre-
feeding skills: A comprehensive resource for Feeding
development. Tuscon, AZ: Therapy skill Builders.
Pearlman, A., & Schulze, K. (Eds.) Deglutition and its
disorders. San Diego: Singular Publishing. Pearlman,
A.L. (1991). The Neurology of Swallowing. Seminars in
Speech and Language. Vol. 12, #3. New York, NY: Theime
Medical Publications, Inc

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SPECIAL THANKS

 Tania Stegen-Hanson, OTD, OTR/L, BCP, C/NDT, CEIM

 Debra Beckman ,oral hypersensitivity scale

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