Co-occupation in feeding and the child’s eating skills is an important role of the occupational therapist.

For the child, ability to participate in mealtime is influenced by performance components such as oral sesory and motor function, physiologic and cognitive parameters.

For the parents other factors influence her occupational performance as the feeder, including informal ideas about feeding a child.

Because of the complexity and importance of feeding and nutritional intake, a collaborative interdisciplinary approach is recommended with the family for a intervention plan.

The occupational therapist helps the child to develop eating skills that allow for growth and development and help the family gain confidence.

Disorders of sucking, deglutition, mastication

Concern for feeding has different phases, from sucking breast milk until self-feeding a complete menu at mealtime using the requiredcutlery.

Feeding issues are various, depending on the child’s development and his health.

Premature babies, those born with congenital problems (e.g. cardiac problems), or those with cerebral palsy (CP), lack the energy to suck or even the sucking reflex.

Anatomical structures of the mouth and throat suffer significant changes in the first 12 months of life.

Fig nr.1 Sagittal section of the oropharyngeal area

Sucking

When the nipple (or bottle) is inserted into the mouth, the enables the baby to automatically compress the nipple and automatic sucking is achieved. A negative pressure is created which extracts the milk.

The sucking reflex in the full term new born baby is present from the foetal stage and is preserveduntil 8-10 months of age.

The nutritive sucking mode is rhythmic, with breathing pauses followed by bursts of sucking. (19) Sucking the dummy (non-nutritive) is quick,about 2sucking movements per second.

Premature baby of less than33 gestational weeks has non-nutritive sucking,without vigour, and it will be fed by nasogastric tube.

After 35 gestational weeks, tongue and jaw movements are strong enough to achieve nutritional sucking. At 36 weeks, the premature baby has the sucking pattern of the full term newborn. The full term baby displays strong oral reflexes, rooting reflex is present, displays coughing reflex, which protects him against false paths indeglutition.

The first way of sucking lasts for about four months, is characterized by back and forth movements of the tongue, accompanied by movements of the jaw. (20). It is the sucking way, which occurs before the maturation of the oral motor centre.

Mature sucking appears after four months, when the tongue moves in the craniocaudal direction and jaw movements are reduced.

At 6 months, craniocaudal tongue movements are strong, with minimal excursion of the mandible. At 9 months, the baby sucks the nipple well, but he will switch to the primary wayof sucking if he passes to the cup, but he will adapt quickly applying the upper lip on the cup, to facilitate entry of fluid into the mouth opening and tongue ensures penetration into mouth. (15) At 24 months, the child normally drinks from a cup, with craniocaudal movements of the tongue; he swallows easily anddoes not lose fluid.

Breathing is slowed downduring sucking and is performed between sucking sequences. If incoordination exists between sucking, deglutition and breathing, the child will cough. After 9 months, the baby stops breathing during 3-4 sucking sequences. At 12 months,deglutitionfollows sucking without pause; the infant will swallow 3 times before the pause. At 15-18 months, there is perfect coordination between sucking, deglutition and breathing. (18)

Biting and mastication

At 4-5 months, there is a stereotype: “bite and release” of an object with up and down movements of the mandible.

In the next phase, the child is “munching” the puree; jaw movements are vertical and the tongue performs movements of extension and retraction.

At 7-8 months,food texture being different, there are diagonal jaw movements.

At 9 months, baby transfers the foodwith the tongue from the centre to the sides of the mouth, encouraging the beginning ofmastication. At 24 months, the child bites easily, being able to eat raw vegetables.

The mandible has circular movements, characteristic to mastication; the tongue performs twisting movements, transferring food from one side to another, cleans lips and gums. (2.4)

Self-feeding

Just before 6 months of age, the baby puts his hands on the bottle, wanting to keep it. At 8 months, the baby grabs a biscuit with radial graspping and at around 9-13 months self-feeding skills start developing. At 12 months, babyclutches the spoon withoutadjusting hisforearm and wrist positions. The ability to eat with spoon occurs between 15-18 months, baby mobilizing his shoulder, with forearm pronation. At 24 months, he eats solid food spoon without spilling it. At 36 months, he starts using a fork.

Drinking

Ability to drink from the cup is improvedat around 12 months, when the baby is able to tip the cup to his mouth without spilling. The baby is able to drink with the straw at about two years of age, when he closeshis lips well.

Assessment of the child (16)

The therapist will inquire about: psycho-motor behaviour, the time necessary for feeding, the type of food that is fed, if there is gastroesophageal reflux or vomiting, feeding method, the neurological assessment the child has performed, whether there was a history of lung disease, which can affect deglutition.

Observation of the child feeding

• The therapist will be able to play with the baby before he is fed, observing his motor and cognitive skills.
• Food will be the usual.
• The parent will feed the baby, while the therapist will observe deficiencies in sucking or mastication, ordeglutition, the way the parent encourages the baby.
• Then, the therapist will feed the baby, while observing the child in different positions, with different foods and textures.
• He will alsoconsider: postural control, movement of lips and tongue, coordination of movements.
• Videofluoroscopic Study (VFS) of swallowing: barium food mixture allowing the radiologist to follow the food tract on the monitor of an x-ray machine and to see how swallowing is performed, whether there is suction, etc. (21)
• The therapist will have to distinguish penetration from aspiration with the help of VFS.

Penetration:passage of the bolusthrough the airways before or during swallowapnea.

Aspiration entering of bolus intothe airways after swallowing, aided by inhalation when breathing is resumed. (11,12)

These aspects are very important in children with motor problems and increased risk of aspiration. The therapist will determine the child’s posture and texture of foods to avoid aspiration. (21)

Interventions in sensitivity disorders

At solid food introduction,children with feeding problems frequentlymanifestintra and perioral hypersensitivitytherefore they spit, cough and choke.

Oral Hypersensitivity has three causes:

1. It is associated with resuscitationissues (intubation, nasogastric tube, which generated cough, sensation of drowning).
2. Children who have not fed through the mouth for a long time.
3. Children with neurological immaturity (CP, Autism, ADHD). (17.19)

• The therapist will start the session with relaxing gaming to establish psychological comfort and therapist-patient relationship.
• Then, he will move to desensitization, encouraging baby to suck fingers, or he will place rubber toys in the baby’s mouth stimulating with them different areas of the mouth.
• With a damp cloth napkin, the baby’s gumswill be pressed, allowing him to suck or chew the corners of napkin.
• Or, with the therapist’s finger inserted into the nipple, pressures on the gums will be performed, or massaging the gums with toothbrush. (13.15)
• In older children, blowing toys may be used.
• Or, small rubber toys are inserted in the mashed food, which the baby will discover.
• Pressure with the therapist’s finger on the outside of the baby’s lips, tongue, palate and cheeks will be performed. (12,14)
• Vibrationsat the level of the jaw and around the lips – they decrease sensitivity.
• Castillo-MoralesPressures.
• Desensitization starts before main meals and may begin by applying warm compresses around or inside the mouth. Also,it begins with caressing the baby.
• It should benoted that food placed in front of the mouth is tolerated better than when it is placed in the rear and even better,when it is placed in the centre than on the sides of the tongue.

Intervention in cases withmotor disabilities

In some cases there is a hypotony of the facial muscles, the mouth is slightly open, deglutition is difficult, the tongue is inactive, and the patient displays jaw instability, inactivehypotonic lips. Postural instability coexists with lack of head control and neck flexion.

In other cases, there is a hypertony of the face, with hyperextension of the neck and trunk. These children have distinct behaviour: they have atonic bite, with sudden closing of the mouth, especially when poorly positioned, with neck in extension, project their tongue out of the mouth, eliminating foods, having increased facial tone, they retract their lips when their bottle or the spoon approaches the mouth, making feeding impossible.

Assessment

• Assessing motor skills, muscle tone, postural alignment
• Assessing cheeks, tongue, jaw and lip movements
• Assessing coordination of sucking-deglutition-breathing sequence
• Observing how oral movements are affected by the position of the child.

Intervention

POSTURAL ALIGNMENT:

• The baby in his mother’s arms, in lateral decubitus–it is a tiring position for the mother who cannot keep a correct alignment.
• The baby remained on mother’s thigh, facing her, or on a cushion – posture with stability and good alignment, eye contact is possible, so communicationis ensured.

Fig. 2 Infant positioning

• The baby is seated on a chair –it is the case of a baby with good control of the head, but who did not acquire the seated posture. The chair will be customized for a symmetrical posture. This system is not suitable for infants with major imbalance in the seated positions, or more with than 11 kg.
• The child is seated in the chair type “Tumble Forms” – has good head control, good positioning of the trunk, can be firmly secured with straps and the seat can be tilted at the optimum angle.

Fig. 3 Positioning in the “Tumble Forms” type of chair

• The baby is seatedin the car seat, which is similar to “Tumble Forms”. This chair provides stability and good alignment.
• Seated in regular stroller or wheelchair – they provide a good positioning: support thehead, have side supports and straps, therefore they provide a neutral pelvis position, with a flexion angle of hips and knees of 900.
• The baby is placed in a high chair – this mode of feeding may be used for children with good motor control, who learn to eat solid food. It is good to be provided with lateral support for legs.

MANEUVERS IN SUPPORT OF ORAL MOTILITY (9, 12)

• Plugging or slight elongation of the cheeks, lips, with the aim to increase perioral tone in children with hypotony of this area.
• Vibrations in the cheeks that arealso hypotonic.
• In cases of hypertonia of the lips, cheeks and tongue, rhythmic pressures performed on the patient’s chin and cheeks, to inhibit lip retraction .
• Placing the therapist’s finger or the convex side of the spoon on the tongue, with rhythmic pressures (one per second). These pressures are performed on the front of the retracted tongue, or posteriorly, for theextended language.

MANEUVERS DURING FEEDING

The therapist will provide support in the jaw, with the thumb putting pressure on the front of the chin, for loweringthe jaw. Medius will be placed under the chin ,favouring stability, and the index will put pressure on the cheek, creating a negative pressure in the mouth, favouring infants to empty the bottle. It is the “the 3 point grasp”.

Fig. 4 The “3 point grasp”

Fig. 5 The “3 point grasp”

Fig. 6 The “3 point grasp”

Pressure of the bottle or of the spoon downward, in the centre of the tongue, will facilitate sucking, therefore it is recommended in children with exclusive pattern of sucking, with tongue movements in extension or retraction. It will favour top-down movement of the tongue, characteristic to mature sucking.

At the beginning of the of the masticationpattern, the spoon will be placed in the side of the mouth to encourage tongue lateralization. Foods placed at the side, near the gum, stimulate mastication.

The spoon will not be placed at the back of the tongue because this favours the aspiration of food into the trachea.

Head and shoulder position is important – support will be provided in the posterior of occiput for a correct swallowing, preventing aspiration.

MODIFYING SENSORY QUALITY OF FOOD

The child must gradually adjust to different food textures. Liquids are less controllable in the mouth and will be replaced with dense foods in children with poor tongue control. Purees stimulate sucking and deglutition.

Introduction of dense foods facilitates tongue laterality and activateslip mobility and mastication.Some foods increase muscle tone and mastication, for example apples, apricots.

The efficacy of sensory-motor treatment in children with CPhad been studied for 10-12 weeks (11).

Treatment has been applied for 5-7 minutes, five days a week, using tongue lateralization, lip control, following mastication force. The progressive introduction of new textures during snacks and lunch has been monitored.

After intervention, meals duration has been decreasedand children have progressed to accept more dense textures.

Interventions in deglutition problems

DEGLUTITION AND SUCKING – DEGLUTITION – BREATHING COORDINATION

Normal phases of deglutition:

• Oral Phase: food is introduced into the mouth,it is processed, projected to the centre of the mouth, then to the base of the tongue, where deglutition starts. It is a reflex response to the presence of food in the back of the tongue.
• PharyngealPhase: bolus from the pharynx is mobilizedinto the oesophagus due to the negative pressure. The larynx is protectedinto the trachea by closing the epiglottis.
• Oesophageal Phase: bolus or the liquid passes through the oesophagus by peristalsis.

Therapeutically, we insist on control of the oral phase.

Children with oral motor dysfunction are unable to form a bolus; food leaks outside edges of the tongue, spreads in the mouth and may fall into the pharynx. Since deglutition is not triggered, closing of epiglottis does not occur, aspiration of food is possible.

Children with breathing disabilities have an increased risk for deglutition dysfunction, with shallow and rapid breathing, which prevents a rhythmic deglutition. The child tries to breathe and swallow at the same time.

ASSESSEMENT OF DEGLUTITION DISORDERS

Requires knowledge of the following data:

• – Medical history of the child
• – History of feeding method
• – Observing the child during feeding
• – Videofluoroscopy

INTERVENTIONS

INITIATING RHYTHMIC DEGLUTITION

• The muscles involved in deglutitionmay be activated, applying cold stimuli on the tongue and soft palate with a frozen pacifier. Deglutition reflex will take place more easily. (19)
• In older children, ice cubesare used before feeding and during meals.

STIMULATION OF ORAL TRANSIT

• Good positioning of the head and jaw.Mandibular supportfacilitates the closure of the mouth and tongue motility, thereby increasing the pressure in the oral cavity, and the efficiency of deglutition.
• Correct positioning in mild neck flexion, favouring closure of the path to the larynx during deglutition, preventing aspiration.

INTERVENTION DURING FEEDING

In children with respiratory deficiencies, incoordination of sucking-deglutition-breathing sequence is problematic.Placing the child in the upright position is recommended.It is recommendeda technique to discontinue sucking, by removing the bottle from the baby’s mouth, to enable the child to breathe and relax. (12)

NON-ORALFEEDING

In case of serious deglutition deficiencies, including the presence of aspiration, recourse to nasogastric tube or gastrostomyis recommended. Using non-oral feeding does not exclude the oral one. Feeding smaller quantities of food before non-oral feeding, or even during it will be tried.

TRANSITION FROM NON-ORAL TO ORAL FEEDING

• The therapist will work to desensitize the area around the mouth and inside it. We start by sucking and chewing rubber toys, using a toothbrush or a warmed cloth.
• Gradually, small quantities of foodwill be offered through the mouth, while the baby is fed through the gastrostomy tube. (17)
• The child will be fed through the tube 4-5 times a day, then e the amount of food will be reduced by 25%, to stimulate hunger, trying to gradually introduce oral nutrition. (17)
• If the child does not tolerate losing weight by reducing caloric intake, oral feedingis abandoned for a period of time.

INTERVENTION FOR ORAL STRUCTURAL PROBLEMS

• Cheilopalatoschisis- affecting 1/700 children in the United States. New borns with this malformation cannot maintain negative pressure in the mouth and this poses serious challenges to feeding until surgical correction.
• Micrognathia (small and retracted jaw) also raises feeding problems, mouth and tongue with an abnormal positioning in relation to the jaw.

There are special bottles for these caseswhich compensates the negative pressure and limitation of lingual mobility. There is also a type of prosthesis that covers the palate defect, preventing fluids from escaping in the nasal passages. (8) In the West,there are also bottles that can adjust the liquid flow through the bowing of the bottle rim.

Children with palatoschisis or micrognathiashould be positioned vertically during feeding to reduce the risk of aspiration; it is a posture causing some anteduction of the retrognation, thus preventing nasal and pharyngeal aspiration. (8)

INTERVENTION IN SELF- FEEDING

The delay in the occurrence of self-feeding is due to cognitive, motor or sensorydeficits.

Intervention strategy includes proper positioning, handling techniques, and adapted equipment. Positioning of the head-neck-trunk in rectitude is comfortable for self service, then lowering the chin and shoulder, pelvis in neutral position. The baby will be installed at a high mobile table optimally with footrest and forearms support, adequately sized chair.

In the techniques of handling cutlery, the following issues will be considered for improvement:

• mobility and stability in varying degrees of supination
• wrist stability
• grasping with thumb opposition
• isolated movements of the thumb and motility of fingers IV and V
• control the transverse metacarpal arch
• dissociation between the radial and ulnar zones of the hand.

Development sequences of grasps

In motor development ofupper limbs, wrist stability is important for the control of distal fingers. In the first months, the baby has no voluntary movements of the hand that opens and closes to various sensory stimuli. Gradually,grasp reflex (grasping) decreases and the voluntary grasp develops. At 4-5 months of age, there is an increased grasping ability, and at six months the child uses palm grasping. (5) At 9 months, the child catches a small object between the thumb and index. Between 9-11 months,there is an improvement of end-to-end thumb-index grasp for small items. Between 12-15 months, baby catches a biscuit and other flat objects having a better control of the intrinsic muscles of the hand. At this age, he uses the digit-palmar translation to pick up a small object. At 2-2½ years, the child uses palmar-digital translation, and at four years, wrist rotation is complete. At 5 years, palmar grip is well developed and it continues to improve in the first school years.At 6-12 years, bimanual skills are more complex and efficient. The development of manipulation within the hand is also important and needs attention.(10).

Regarding bimanual hand use, 3-10 month baby catches objects with both hands and bring them to his mouth, at 10 months a hand catches the object, and the other hand manipulates a part of it, and at 17-18 months, one hand stabilizes the object, the other handles it, so the two sides of the body dissociate themselves.Between 18-24 months, skills are improving, and up to 2 ½ years bimanual use becomes mature.

Therapist’s interventions:

• Facilitate descent of the shoulders, scapular stabilization and humerus guidance, which will ease the hand-mouth gesture.
• Provide support and stabilize the intermittent arm to cause the child to perform the movement by himself, too.
• One of the techniques: the therapist will stick the spoon into the palm of the child, and will place a finger in his palm, whilethe therapist’s thumb and will stay on the back of the patient’s wrist. This will facilitate the extension of the latter’s wrist and will apply pressure in the palm of the child. (13)
• Appropriate cutlery, mugs with lids, etc. will be used.
• Children with tonus abnormalities, such as ataxia with tremor of the hands, who lose the contents of the spoon,will be taught to stabilize food with the help of a blunt fork.
• Due to the complexity and importance of nutrition, interdiscilplinary collaboration is self-evident, including family training.

Problems of feeding disorders in infants and small children are many and difficult. They require patience, persistence, and experience in this field.

Currently, their resolution rests with physicians specializing in rehabilitation of child, with psychologists and physical therapists.

In our country, there are finally two universities specializing in occupational therapy. We hope that their curricula will also include infant and toddler issues.

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