Feeding

Foundations of Feeding, Eating, and Swallowing in Occupational Therapy

  • Feeding, eating, and swallowing are critical components of health and wellness, contributing significantly to a child's social, emotional, and cultural development.

  • Clinicians must monitor for specific clinical observations that suggest a swallowing problem:

    • Gagging, coughing, or choking during meals.

    • Reflux issues.

    • A "wet" vocal quality or gurgling voice.

    • Frequent respiratory infections or occurrences of pneumonia.

  • Dysphagia: Defined literally as difficulty swallowing. This condition impacts a child's ability to eat safely and often requires interprofessional collaboration (e.g., referring to or collaborating with a speech-language pathologist).

  • Associated Medical Diagnoses:

    • Prematurity.

    • Neuromuscular abnormalities.

    • Structural malformations.

    • Gastrointestinal conditions.

    • Visual impairments.

    • Tracheostomies.

    • Autism Spectrum Disorder (ASDASD).

Anatomy and Physiology of Oral Structures

  • Oral Cavity Structures:

    • Tongue: Central for manipulation and movement of food.

    • Cheeks: Provide the boundary for the oral space.

    • Pockets: The space between the cheeks and teeth where food can potentially become trapped.

    • Hard Palate: The bony front part of the roof of the mouth.

    • Soft Palate: The muscular back part of the roof of the mouth.

    • Fascial Arches: Located at the back of the throat.

  • Functional Anatomy:

    • Pharynx: Funnels food from the mouth into the esophagus.

    • Larynx: Acts as a valve to the trachea; it must close during swallowing to protect the airway.

    • Epiglottis: The specific structure that covers the airway during a swallow.

    • Trachea: The airway allowing flow into the bronchi and lungs. It briefly closes during every reflexive swallow.

    • Esophagus: The tube that carries food from the pharynx into the stomach.

The Four Phases of Swallowing

  • Oral Preparatory Phase:

    • Involves oral manipulation of food to form a bolus.

    • Characterized by chewing and tasting; remembered as the "pleasant" phase.

  • Oral Phase:

    • The bolus is moved posteriorly toward the pharynx.

    • This movement ends when it triggers the swallow response.

  • Pharyngeal Phase:

    • The swallow is triggered.

    • The larynx/epiglottis closes the airway, and the esophagus opens to receive the bolus.

  • Esophageal Phase:

    • The bolus enters the esophagus and travels down into the stomach.

Developmental Milestones for Chewing and Motor Control

  • 33 to 66 Months: Symmetric, immature oral motor movements, specifically "munching" (symmetric up-and-down movements where everything moves together).

  • 88 to 1212 Months: Vertical chewing movements begin. Dissociation between jaw and tongue movement starts, allowing the tongue to work in more isolation.

  • 1212 Months: Rotary chewing skills develop, including diagonal jaw movements and lateral tongue movement.

  • 55 Years: Fully functional adult patterns of chewing are established.

  • Safety Note: Highly choke-prone foods should not be introduced before 33 years of age, as mature tongue movement and oral motor control are required to prevent aspiration.

Evaluation and Diagnostics

  • Comprehensive Evaluation:

    • Occupational Profile: Gather history via parent interviews, chart reviews, and questionnaires.

    • Physical Evaluation: Assess muscle tone, movement abilities, sensory processing, and overall development.

    • Structured Observation: Inspect outer oral structures for symmetry and tone, and inner structures for range of motion (ROMROM) of the tongue and lips.

    • Naturalistic Observation: Observe feeding in a familiar home routine with primary caregivers.

  • Diagnostic Studies:

    • Video Fluoroscopic Swallow Study (VFSSVFSS): Also called the Upright Modified Barium Swallow Study.

    • Purpose: Identifies aspiration or risk of aspiration, detects positioning issues, and determines safe food/liquid consistencies.

Food Texture and Liquid Consistency Levels

  • Food Texture Levels:

    • Level 1: Pureed: Homogenous and cohesive textures (e.g., pudding).

    • Level 2: Mechanically Altered: Moist, semi-solid foods requiring minimal chewing (e.g., ground/minced meats, fork-mashed soft fruits/vegetables).

    • Level 3: Advanced: Soft solid foods requiring more chewing (e.g., crackers, breads, cooked vegetables, soft fruits, and meats).

    • Level 4: Regular: No restrictions whatsoever.

  • Liquid Consistencies:

    • Thin: Includes water, juice, milk, broth, and items that melt (e.g., ice cream, ice).

    • Nectar: Consistent with tomato juice or natural fruit nectars/yogurt smoothies.

    • Honey: Thick consistency that drips slowly off a spoon, mimicking actual honey.

Core Conceptual Frameworks for Intervention

  • Same Rules, Different Game: General OT principles apply to feeding but focus on the mouth (e.g., providing proprioceptive input via chewing or facial massage to help with sensory integration).

  • Making the Grade: Use the "just right challenge" to build tolerance for sensory aspects or physical endurance of chewing muscles.

  • Layman's Logic: Prioritize safety (aspiration/choking risk) first. If a client is NPONPO (nothing by mouth), prioritize oral exploration and non-nutritive activities.

  • Proximal Stability Results in Distal Mobility:

    • The hierarchy of stability for feeding:

      1. Pelvis and Trunk.

      2. Head and Neck.

      3. Jaw Stability.

      4. Tongue and Lip Control (Distal).

  • Hypo vs. Hypersensitivity:

    • Hypersensitive: Requires desensitizing/calming techniques.

    • Hyposensitive: Requires arousal techniques.

Specific Interventions and Adaptive Equipment

  • Cranial Nerves (CN) Involved:

    • CN I (Olfactory): Sensory for smell.

    • CN V (Trigeminal): Sensory for cheeks/lips/teeth; motor for mastication.

    • CN VII (Facial): Sensory for taste (anterior 2/32/3 of tongue); motor for facial expression/salivary glands.

    • CN IX (Glossopharyngeal): Sensory for taste (posterior 1/31/3 of tongue); motor for swallowing/salivary glands.

    • CN X (Vagus): Sensory for pharynx/larynx/esophagus; motor for pharynx/larynx.

    • CN XII (Hypoglossal): Motor for tongue muscles.

  • Positioning:

    • Chin Tuck: Slight flexion to close the airway and reduce aspiration risk.

    • Midline Orientation: Trunk, head, and neck should be aligned in midline with slight flexion of the hips.

    • Progression: Side-lying is natural for breastfeeding; elevated supine/upright is used around 44 to 66 months; side-lying can be used late in life for extreme weakness.

    • Avoid: Flat supine positions and propping bottles on the chest.

  • Environment:

    • Lack of hunger: Consistent meal times.

    • Wandering: Consistent sitting location.

    • Limited intake: Longer meal times (1515 to 3030 minutes).

    • Weakness: Shorter duration meals.

  • Oral Motor Issues:

    • Tonic Bite/Tongue Thrust: Place food laterally (on the sides).

    • Suckling: Apply slight pressure with a finger to the middle of the tongue.

    • Jaw Weakness: Non-nutritive chewing/sucking.

    • Clearing the Throat: Second swallow with verbal cues or empty spoon cue.

  • Adaptive Equipment:

    • Shallow Bowl/Spoon: For decreased lip closure.

    • One-Way Valve Straw: Keeps liquid in the straw; used for poor lip seal/insufficient suction.

    • Bumps/Ridges or Chilled Spoon: For sensory registration/hyposensitivity.

    • Rubber Spoon: For bite reflex (protects teeth).

    • Nosy Cup (U-Shaped/Cutout): Allows drinking without neck extension (conforms to the nose).

  • Sensory and Behavior:

    • Arousal (Hyposensitive): Cold temperatures, vibrating toys, strong flavors.

    • Calming (Hypersensitive): Deep pressure, self-directed play, gradual texture introduction.

    • Behavioral: Offer structure, routines, choices, and positive reinforcement. Avoid "grazing" outside of meals.

    • Critical Referral: If a child is so selective they risk malnutrition (e.g., won't eat "French Fries"), the initial action is to refer to a physician.

Self-Feeding and Specialized Populations

  • Physical Impairments: Raise the tray table or have the child support themselves with elbows on the table.

  • Coordination/Ataxia: Use Dycem to stabilize bowls, lids to prevent spills, and long straws.

  • Cleft Lip and Palate:

    • Positioning: Upright feeding (>60∘>60^∘) to prevent fluid leaking from the nose.

    • Tools: Specialized squeeze bottles and long, soft nipples with one-way valves for easier latching and flow control.

Practice Application Review

  • Case 1 (14yo, Moderate Hypotonia): Recommended position is torso supported in a slight recline with head and neck at midline. Recline helps compensate for poor postural control.

  • Case 2 (4yo, Spastic CP, Poor Lip Closure/Suction): The most beneficial adaptation for drinking independence is a specialized one-way valve cup. This allows fluid to stay in the straw between small suction efforts, accounting for poor lip seal.

  • Logic Note on Nosy Cups: These are specifically used to prevent neck hyperextension during drinking.

The Key Line

  • "Don't eat your pets; eat French Fries instead."

    • PP: Positioning.

    • EE: Equipment.

    • TT: Transitions.

    • SS: Sensations.

    • French Fries: Remember the referral to a physician for extreme food selectivity.