Category Archives: Oral Motor

Oral Motor Treatment Strategies: Part 1

Oral Motor

On Tuesday night Therapro was happy to host an overwhelmingly popular webinar presented by Dr. Kate Barlow on the topic of Oral Motor Treatment Strategies.  Dr. Barlow is an Assistant Professor at American International College. She is also the current ambassador for the CDC’s Learn the Signs Act Early program for the state of Massachusetts. She has over 20 years of clinical experience including public school practice, early intervention, and a pediatric hospital-based outpatient clinic, as well as management. Dr. Barlow’s passion is in global outreach; she founded the International Interprofessional Mentorship Program that currently provides mentorship to over 100 therapists in developing countries in Africa and South America.

Dr. Barlow’s extensive knowledge in this area was evident as she seamlessly broke down this complex topic into manageable bits of information. Dr. Barlow set out with the main objectives of providing viewers with specific intervention strategies for oral motor deficits and relaying the importance of screening all children for feeding difficulties. As one viewer stated:

“This was one of the best courses I’ve taken in a long time. The instructor was knowledgeable with practical assessment and treatment strategies that I can even use in collaboration with SLPs. So many OTs are intimidated to address feeding, especially in the school setting, but I think it is so important!” -LB

Viewers left with some great take-aways that we will recap in this post:

1.) Guidelines for making food recommendations. 

2.) The importance of enjoying food.

3.) All children should be screened for feeding disorders.

Guidelines for Making Food Recommendations. Match food choice with skill level. When Dr. Barlow discussed guidelines for recommending appropriate food choices, she stated simply  “look at the child in front of you and where they are developmentally.” This bit of advice was a great reminder for new and experienced therapists alike; a child’s skill level isn’t necessarily defined by their age. Dr. Barlow highlighted this further by showing that the development of circular rotary chew could occur on a widely varied timeline, anywhere between 18 to 36 months! 

The Importance of Enjoying Food.  Another important takeaway from Dr. Barlow’s webinar was the importance of enjoying food. She spoke passionately about the importance of understanding underlying medical problems when addressing feeding difficulties. Dr. Barlow explained that behavioral problems around eating can often be addressed when the feeding difficulty is appropriately treated. Another point she raised is the importance of a child being included at the family table. She stressed the importance of this inclusion, in whatever capacity the child is capable (even if it meant that they were just sucking on a lollipop), because the mealtime experience is an important cultural ritual.    

All Children Should Be Screened for Feeding Disorders.  A third take away from Dr. Barlow’s webinar was the importance of screening all children for feeding difficulties regardless of why that child is on your caseload.  She highlighted the prevalence of feeding difficulties as a key factor in this; I was struck by how prevalent feeding difficulties are even in typically developing children.  Dr. Barlow cited research indicating feeding difficulties are present in one in four typically developing children. In children with developmental disabilities and cerebral palsy, the prevalence is significantly greater.  With this information I found myself reflecting on all that I knew about the role of nutrition in supporting optimal behavior for participation.  The concept of screening all children for feeding difficulties truly makes sense when considering the prevalence of feeding difficulties and the role that nutrition plays in a child’s ability to attend and participate in all of their daily activities.  

A great resource for information on these topics is a book published by Therapro: Pediatric Feeding Disorders Evaluation and Treatment.  It covers topics ranging from the progression of feeding development, to the role of the gastrointestinal system in feeding difficulties, to the evaluation of feeding difficulties, along with a broad range of other feeding topics!  Stay tuned for future blog posts where we continue our review of Dr. Barlow’s webinar, exploring her tips and suggestions for screening pediatric feeding difficulties as well as some of her great treatment strategies! 

Feeding Therapy: What to Do When You are Stuck

Feeding Therapy, Oral Motor

By Krisi Brackett MS SLP-CCC

I get emails all the time asking for advice on how to get kids to eat. Many of these children are in therapy but are having difficulty progressing toward the acceptance of food and liquid. I have said this before but will say it again, these kids are hard, feeding intervention can be challenging and what works for one child may not work for another. As a feeding therapist, I am a believer in working on the goal of “improved acceptance of volume and variety of foods” from the standpoint of health and nutrition (kids need to eat from all food groups) and also because if a child is orally feeding then they are using and developing their oral-pharyngeal muscles which helps with oral motor skill development. I cannot stress enough that these children are all unique and need to be assessed individually but I thought I would try to come up with a top ten (really twelve) list of ideas to break the plateau. I hope these ideas help to generate some progress!

  1. Look more closely at medical reasons for refusing food. This might include gastroesophageal reflux, constipation, food intolerance, eoscinophillic esophagitis, increased work of breathing, respiratory problems, dysphagia, or poor appetite. Consider working closely with a primary care physician, developmental pediatrician or gastroenterologist to obtain further assessment and trial some medical management strategies.
  2. Refer to a multidisciplinary Feeding Team. Sometimes two or more heads are better than one meaning a feeding team may be able to assess a child who is not progressing and come up with some new ideas to jump start things. Typically you can find a multidisciplinary feeding team in a children’s hospital. We do this all the time for our kids in NC!
  3. Increase the child’s appetite. Some of the children we work with have a history of poor appetite, volume limiting, or have been tube fed and do not have a reference for hunger/fullness. An appetite stimulant may help in getting a child eating (this tends to be more effective after medical management strategies have been implemented or when you are certain the child is not in pain).
  4. Manipulate tube feedings. Many clinicians have the goal of getting a child to bolus feeds to simulate normal eating but for some children, especially those with underlying abnormal motility this will not necessarily encourage intake. Manipulating tube feeding schedules to allow a significant amount off time off the tube to develop hunger or an opportunity to orally feed or changing the type of formula to something predigested which may have a faster gastric emptying time can be effective strategies to encourage intake.
  5. Alter supplement intake. Sometimes when a child is drinking a supplement either for meals or extra calories they develop a preference for the sweet taste of the formula and may refuse food to get the formula or because they are full. Try altering how the supplement is given by offering smaller amounts during meals (example, 4 oz instead of 8 oz), giving it after meals or at snacks only.
  6. Consider an intensive feeding program. I am always surprised to hear that feeding therapists do not know these programs exist. There are intensive feeding programs around the country (in the U.S.), typically housed in a childrens hospital, ( I admit I am not sure what is available in other countries) that will provide intensive feeding intervention daily for 4-8 weeks depending on the program. Intensive feeding program are not all the same. These feeding programs have different philosophies on intervention and vary on length of treatment and follow-up. I always give advice to caregivers who are interested to pick a program based on their child’s needs and not just based on geographical location. Many insurance companies will cover these or a portion of the cost if a child has “failed” out patient treatment.
  7. Try a different therapeutic technique. There are many different therapeutic techniques and strategies some more formal than others to encourage intake. If you are using an oral-sensory based feeding approach and are stuck consider trying some behavioral strategies.
  8. Reach out to your colleagues. There are many professional involved in feeding each with a unique skill set to bring to the table. Try reaching out to a feeding therapist from another discipline, a different profession or an expert for ideas. Many clinicians will be open to discuss a client over the phone or via email to generate some ideas.
  9. Take a break from therapy. Sometimes a child or a parent may need a break especially if they have complicated medical needs, may be in and out of the hospital with illness or surgical needs, or have other extenuating circumstances. There are children where oral feeding may not be the priority. For these children we want to make sure they are receiving proper nutrition for weight gain and growth until they are ready to work on oral feeding.
  10. Work closely with caregivers and give homework. Include caregivers in therapy and have them participate in actively using the feeding techniques. Provide homework so that caregivers can practice therapy strategies daily at home with their children. This builds confidence in the caregiver that they can successfully feed their child and provides the child with positive daily practice! Additionally, if you watch caregivers feed their children you can coach them through difficult meal time behaviors. I often think of myself as a feeding coach.
  11. Match the child’s diet texture to their oral motor skills. Many (actually most) of our clients have some oral motor delay. The child’s diet (food textures) should be consistent with their oral skills. If a child is being given foods that are above their skills level, the result will often be poor intake, refusal, long meal times, food pocketing or holding, and expelling. I have seen children make immediate improvement in mealtime just by taking them back to purees or mashed foods, or making a portion of their meal purees with limited solids (determined by their stamina for chewables).
  12. Work on cup drinking. This if often a good way to move a child off of a feeding tube because it is a direct correlation in terms of calories and nutrients. If the child can drink what is going into the tube (and the child’s weight is good), then it can be deducted from the tube feeding. There are often many options for formulas or supplements to choose from. If the child will not drink the tube feeding formula (or it may be an enteral only formula or one with little to no taste), talk with a dietician and obtain samples of alternative supplements with comparable calories and nutrients or about having the caregivers make their own high cal supplement. It can be motivating for caregivers to see the tube feedings decrease.

Info about the author:

Krisi Brackett MS SLP/CCC is a Pediatric Feeding and Dysphagia Specialist with over 20 years of experience. She is currently Co-director of the UNC Pediatric Feeding Team at the NC Children’s Hospital, UNC Healthcare, Chapel hill, NC. She is also an adjunct faculty member at the Division of Speech and Hearing Sciences, UNC– Chapel Hill. Krisi publishes the popular feeding blog, www.pediatricfeedingnews.com and is co-author of the first chapter in Pediatric Feeding Disorders: Evaluation and Treatment, 2013, published by Therapro. Krisi lectures nationally, sharing information on medical management and therapeutic strategies for handling this special population.