final exam review

Oral Motor learning applies _____ to swallowing/feeding

broadly

general principles of oral motor feeding

• Oral Motor learning applies broadly to swallowing/feeding

• Principles of motor learning

• Based in evidence-based medicine (EBM)

• ASHA defines EBP as integrating all three for high-quality service

• Systematic reviews (e.g., Cochrane) help inform practice

principles include:

• Use it & improve it: active training is key

• Repetition & intensity matter: builds functional gains

• Specificity: task relevance boosts learning

• Age matters: early experience influences outcomes

expected oral motor deficits

• Poor ____: ___ or ____

• Reduced ______ or ____in ___, ___, ___

• Incoordination of ____

• _____ abnormalities (e.g., _____, _____)

• ________ challenges

• Inefficient _______ or ______

• Difficulty with ______ and ______

• Poor ____ stability for ______

• Delayed or uncoordinated ______

• Risk of ____ due to poor __________

• Poor muscle tone: hypotonia or hypertonia

• Reduced range of motion (ROM) or strength in lips, jaw, tongue

• Incoordination of oral structures

• Reflex abnormalities (e.g., persistent tonic bite, exaggerated gag)

• Sensory processing challenges

• Inefficient oral bolus formation or manipulation

• Difficulty with lip closure and anterior spillage

• Poor jaw stability for biting/chewing

• Delayed or uncoordinated oral transit

• Risk of aspiration due to poor oral-pharyngeal timing

what facilitates oral control?

Optimal postural alignment

key components of positioning”

• Head/trunk alignment

• Pelvic stability

• 90/90/90 position (hips/knees/ankles)

positioning adaptions

towel rolls, footrests, side supports

For children with severe motor impairments consider what for positioning?

tilt-in-space, headrests, or specialized seating

Direct approaches (e.g., oral exercises):

• Stimulate structures

• Encourage exploration

• Caution: may be invasive or increase secretions

Indirect approaches:

• Environmental alterations: reduce distractions

• Position/seat: improve trunk and head control

• Communication cues: touch, verbal signals

• Food changes: texture, temp, timing, bolus variation

oral motor strategies to improve lip closure

• Deep pressure to orbicularis oris

• Tactile cueing (e.g., “kissy lips”, lip blocs, straw drinking)

• Play with bubbles or resistive straw drinking

oral motor strategies to increase cheek tone and control

• Tapping or vibration to buccal area

• Cheek stretches and cheek puff games

oral motor strategies to promote jaw grading and strength

• Supported spoon feeding with downward pressure

• Use of chewy tubes or resistive chewing tools

• Biting games with resistive textures (e.g., rubber tubing)

• Jaw support via external hand or adaptive equipment

oral motor strategies to promote tongue lateralization and elevation

• Use of flavored tongue depressors or lollipops

• Tongue "games" (e.g., lick lips, touch nose/chin)

• Spoon placement to encourage midline cupping

• Encourage tongue-palate contact with cold stimuli

Use of ____, ____, and _____

____ or ____ depending on need

vibration, temperature variation, and oral play

Oral alerting or calming strategies

Always pair sensory input with what??

functional feeding tasks

Don’t separate _____ from ____ — integrate when possible

example?

oral motor from feeding

Example: chew tube pre-feed warmup → chewing practice during meal

Modify ____ and ____ based on current motor abilities

textures and pacing

Always monitor ____, ______, and _____

fatigue, tone changes, and safety

example goals

By May 2024, Patient will demonstrate age-appropriate feeding skills by completing 15mL or more via age-appropriate cup with external oral motor supports with no overt signs of distress or refusal.

By May 2024, Patient will demonstrate mature feeding skills by improving mastication skills in order to finish a full meal in <60 minutes with external oral motor supports and no signs of distress or refusal.

picky eaters vs problem feeders

eat how many foods?

picky eaters: Eat at least 30 different foods

problem eaters: Eats fewer than 20 foods tota

picky eaters vs problem feeders

tolerances

picky eaters: Will tolerate new foods on the plate, may even taste

problem feeders: Extreme emotional responses (crying, gagging, tantrums) to new foods

picky eaters vs problem feeders

food groups

picky eaters: Eats from all food groups, though may have preferences

problem feeders: Refuses entire food groups or textures

picky eaters vs problem feeders

loss of food

picky eaters: Gradual loss of foods (due to boredom, illness) is often regained

problem feeders: Foods lost due to negative events (e.g., choking) are not regained

picky eaters vs problem feeders

who can they eat with?

picky eaters: Can eat with the family, even if selectively

problem feeders: Cannot eat with others without distress or separate meal

often related to what type of difficulties?

sensory processing difficulties:

• Over-responsive to smell, taste, texture, temperature, visual input

• Under-responsive to internal hunger/fullness cue

Feeding becomes ______ rather than _______

aversive rather than pleasurable

Behavioral challenges are usually symptoms of what?

sensory distress

picky eaters may benefit from what?

parent education and minor mealtime adjustments

what do problem feeders require?

structured, individualized feeding therapy with sensory integration approaches

Interventions for oral sensory disorders include:

• Food chaining (gradual steps between preferred/nonpreferred)

• Sensory, nutrition, and behavior goals

• avoiding food jags

how to avoid food jags

offer preferred food in a variety of shapes, sizes, presentations to avoid burn-out

Sensory management techniques:

• Use sensory strategies during daily tasks (e.g., brushing,mealtime)

• Whole-body sensory input (weighted blankets, proprioception)

• Adjust environment

• Gradual desensitization

• Modify foods

how would you adjust environment?

lighting, color contrast, quiet space

Gradual desensitization→ start with?

tolerated inputs

how would you modify foods?

visual appeal, temperature, texture

Sensory defensiveness can be linked to:

• Emotional distress or trauma

• Medical history

SOS approach to feeding

• Increases _____, not just ____

• Reduces ____ and ______ around mealtimes

• Builds ___ and ______ with food

• Increases food range (variety), not just volume

• Reduces anxiety and negative behaviors around mealtimes

• Builds trust and positive associations with food

core principles to SOS approach to feeding

• All behavior is communication

• Systematic desensitization

• Child-led progression

• Play-based hierarchy

• Whole-body regulation

All behavior is communication

Feeding refusal often reflects underlying sensory, developmental, or emotional distress

Children are gradually exposed to food in a non-threatening, playful way across 32+ steps of eating—from tolerating food near them to eventually chewing and swallowing

Systematic desensitization

Feeding should progress at the child’s pace — no force-feeding or bribing.

Child-led progression

Uses food play (touch, kiss, lick, bite, chew) to reduce anxiety and build comfort.

Play-based hierarchy

Feeding is a full-body experience; posture, respiration, and sensory regulation must be addressed before oral intake can improve

Whole-body regulation

what should you not write a goal about?

to tolerate something, it is not therapuetic

instead, use accept or engage

common challenges with prematurity

• Poor state regulation

• Weak suck, fatigue

• Incoordination of suck-swallow-breathe

management focus for prematurity

• Ensure physiologic stability before oral feeds

• Optimize nipple flow rate, positioning, and pacing

• Use cue-based feeding vs. rigid schedules

breastfeeding strategies for preterm infants

• Use positioning to support feeding

• Consider hand expressing/pumping to "let down" to reduce fast flow

• Nipple shields

• Consider lactation consult if initial interventions are unsuccessful

common challenges with breastfeeding for preterm infants

• immature latch or suck

• sleepiness, poor endurance

• difficulty coordinating NNS or transitioning to nutritive suck

Benefits of breastfeeding for preterm infants

include immune protection, GI health, and bonding (increased skin-to-skin contact)

POSSIBLE signs that the flow is TOO slow:

• High suck:swallow ratio (2-3:1)

• Prolonged feeding times

• Signs of frustration, hunger and fussiness

• Fatigue

POSSIBLE signs that the flow is TOO fast:

• Gulping, choking, coughing

• Anterior spillage

• Refusal, pulling away

• Eye widening, "overwhelmed" look

what is used to prevent "events" (bradycardia, oxygen desaturation), fatigue, and aspiration?

pacing

Infants, especially premature infants, rely on US to do what?

impose breathing breaks as their lungs are immature

INFANT-based pacing

preferred-watch the INFANT, not the clock

how to do pacing

Tip the nipple downwards to empty and imposes a breathing break and establish a rhythmical pattern to encourage the suck:swallow:breathe behavior.

You can also ___________ to pace, however you do not want to ___________ if possible.

remove the bottle completely; interrupt or break the latch

treatment strategies

• Cheek support (bilateral/unilateral)

• Jaw/chin support

• *Facial boundaries (cheek support + jaw support)

• Resistance on bottle or pacifier

• Upward/Downward pressure towards palate

Assists in building good intraoral pressure, maintaining latch or organization

Cheek support (bilateral/unilateral)

Assists when unable to achieve proper latch, particularly for those that are tongue-tied, have retro or micrognathia or are very disorganized

Jaw/chin support

Assists when unable to maintain latch or organization to nipple to initiate sucking pattern

*Facial boundaries (cheek support + jaw support)

Assists in encouraging larger jaw excursions for improved bolus extraction, engagement in feed

Resistance on bottle or pacifier

Assists with engagement in feed and providing anchor to latch

CAN be reflexive in nature

Upward/Downward pressure towards palate

feeding expectations of toddlers

• ___ and ___ for oral motor skills, independence, and sensory exploration

• Increased self-feeding attempts: ____, ___, ____

• Introduction of ____ and _____

• Emergence of food _____ and potential food ______

• Age and period of rapid change for oral motor skills, independence, and sensory exploration

• Increased self-feeding attempts: finger foods, utensils, cups

• Introduction of family foods and complex textures

• Emergence of food preferences and potential feeding challenges

feeding challenges of toddlers

• Food refusal or selectivity

• Delayed chewing or tongue lateralization

• Inability to manage mixed textures

• Difficulty with cup or straw drinking

• Behavioral dysregulation (tantrums, escape behaviors)

general principles of toddler feedings:

• Maintain structured, predictable _____ (____, ____, ____)

• Use responsive feeding: _____, ____, or ____

• Promote __________ to model eating

• Respect sensory profiles — ____________

• Provide appropriate ____, ____, and _____

• Rotate foods every ___ weeks to reduce food jag risk

• Celebrate _____ over ______

• Maintain structured, predictable mealtimes (same time, place, routine)

• Use responsive feeding: follow cues, avoid force or bribes

• Promote family-style meals to model eating

• Respect sensory profiles — explore, don’t pressure

• Provide appropriate utensils, seating, and portion sizes

• Rotate foods every 1–2 weeks to reduce food jag risk

• Celebrate interaction over consumption

Can begin around 4–6 months old

spoon feeding

spoon feeding Developing skills:

mouth opening, lip closure, minimal loss

~1 month after spoon

cup drinking

Developing skills: jaw/lip control, suck at rim

cup drinking

Mastery ~12–36 months

straw drinking

straw drinking Developing skills:

tongue mobility, suction coordination, UE coordination

chewing

Can begin around 6–7 months

chewing Developing skills:

munching pattern, lateral tongue movement

spoon feeding strategies

• Choose shallow rounded or flat spoons

• Varied spoon presentation styles

• Observe for anticipation of the spoon (mouth opening, engaged)

• Support jaw stability with finger or spoon positioning

Varied spoon presentation styles

• J-scoop technique

• Lateral presentation

chewing treatment strategies

• Start with ___, ____ (e.g., _____, ____, _____)

• Consider mesh or silicone feeders or poly organza cloth to introduce _____ with added safety measures

• Use side placement of food on ____ or ___

• Offer foods that provide proprioceptive feedback (e.g., resistive textures)

• Pair with ____ (_____, ______, ______)

• ____ chewing and use ____ play or “_______” games

• Practice _____ and______ food (e.g., ______, ________)

• Start with soft, chewable solids (e.g., well-cooked vegetables, soft fruits, meltable puffs)

• Consider mesh or silicone feeders or poly organza cloth to introduce chewy textures with added safety measures

• Use side placement of food on molars or gums

• Offer foods that provide proprioceptive feedback (e.g., resistive textures)

• Pair with oral motor tools (chewy tubes, vibrating oral motor tools, nuk brushes if appropriate)

• Model chewing and use mirror play or “chew like a dinosaur” games

• Practice biting and transferring food (e.g., teething biscuits, long veggie sticks)

cup drinking treatment strategies

• Provide external jaw support

• Use small, single sips

• Present with clear instructions and verbal cues when appropriate

• Use visual models and play-based

Provide external jaw support

• Use your hand under the child’s jaw or at the base of the cup

• Helps reduce jaw instability and excessive tilting

Use small, single sips

• Improves control and pacing

• Reduces risk of aspiration for delayed swallow initiation

Present with clear instructions and verbal cues when appropriate

• Bring cup or straw to midline and wait for lip closure to introduce liquid

• Verbal cues when child is able to follow instructions

Use visual models and play-based

• Demonstrate with a doll or cup toy

• Play “tea party” or “cheers” games to reduce stress