Oral Motor Problems and Feeding

oral motor problems

Many times, OT professionals receive referrals for oral motor problems and feeding. It’s through oral motor occupational therapy interventions that kids can move from challenges biting, chewing, and moving food around inside the mouth, to success with eating and trying new foods. Let’s get started!

Oral motor problems lead to difficulty biting, chewing, and manipulating foods. They can cause difficulties with textures of foods, and can be a cause of picky eating! A good place to start is with understanding the development of oral motor skills.

Oral Motor problems

One thing is for sure; individuals can have a huge spectrum of considerations when it comes to oral motor issues. No two kiddos will be alike. That’s why it’s so important to discuss oral motor issues with a professional.

The process of eating is a complex collection of movements patterns with physical and sensory components.

When feeding is a challenge, many times individual oral structures and sensory-motor patterns are a cause. 

If you are questioning whether an eating issue is sensory or oral motor, be sure to take time to explore each consideration. There can be different interventions and strategies depending on the underlying cause of eating difficulties. For example, there are specifics when it comes to issues with sensory food aversions and sensory food issues.

What are Oral Motor Problems Occupational Therapy Addresses?

The oral motor problems listed below are just some of the issues that can impact function in feeding.  

In a small series of blog posts, I have broken down each oral motor problem that occupational therapists typically address. Each blog post includes information about the specific oral motor concern, the reasoning or underlying influences that relate to each oral motor issue, and feeding issues related to the specific oral motor problem.   

This series of blog posts should be a resource for you to find more information relating to how feeding issues are related to specific oral motor problems and how these feeding issues can be addressed in treatment.   

Click on the links below for more information on each oral motor problem area as they relate to feeding. 

  • Mouth Clamped Shut when eating- Consider the child who clamps their mouth shut during meals.  This is usually the biggest sign to a parent that the child is all done eating, is full, or is refusing to eat.  However, it might be an oral motor problem that is actually the cause of the clamped shut mouth.  The child falls back on this technique because it’s worked for them in the past in some way to provide stability, move out of the difficult oral motor exercises, or has resulted in a response from the parent.   

Other oral motor problems include:

  • Tooth Grinding
  • Tonic Bite
  • Jaw Retraction
  • Tongue Retraction  
  • Tongue Protrusion
  • Tongue Thrust      

Kids can have trouble with picky eating and difficultities in feeding when there are oral motor problems. Different types of oral motor problems.

Occupational Therapy for Oral Motor

Oral motor interventions in occupational therapy can cover a variety of intervention techniques. It is essential to begin with an evaluation and individualized assessment by a feeding professional. Occupational therapists are trained in this area, but some OTs have additional certifications.

The list of occupational therapy oral motor strategies listed below is for educational purposes only and not a replacement for therapy of any kind.

Some occupational therapy oral motor strategies that can be used are:

  1. Oral motor assessment- It is essential to start with the assessment process for safety of the individual. Addressed in more detail below.
  2. Oral motor stimulation- In occupational therapy, strategies include brushing to the lips or cheeks, towel stimulation, feeding swab, tongue mobility exercises, etc. These are explained in greater detail below.
  3. Oral Motor Exercises– We’ve listed a larger list of specific exercises to use in play and in therapy sessions.
  4. Oral motor coordination exercises– Use the oral motor cards in the deep breathing kit to improve oral motor coordination skills. Try mimicking the movements by using a mirror and visual modeling.

Oral Motor Assessment Occupational Therapy

Assessment occurs by a pediatric occupational therapist, but there are many things to be considered.

Feeding is developmental and it’s essential to consider the level, age, and abilities of the individual as this will impact all aspects of feeding and oral motor considerations.

Oral motor assessment and infants-

In infancy, oral motor skills are both a means for self-regulation (nurturing through sucking) and nutritive. Things to consider in an occupational therapy oral motor assessment for infants and babies at this age and stage:

  • Is the infant able to suck in exploration for nipple of bottle or breast?
  • Does the infant suck in bursts and have pauses to allow for breathing while eating?
  • Assessment of the physical mechanics of swallow
  • Timing of sucking and pauses- sucking should occur at a rate of about one suck per second with pausing to swallow the liquid and breathing. This should occur in a coordinated manner.
  • Lip closure
  • Jaw movements to draw liquid into the mouth and to swallow (infants)
  • Anterior tongue movement during the sucking, along with cheek movement and jaw movement as the tongue draws milk or formula to the rear of the mouth to swallow (older babies)
  • Oral reflexes and whole body primitive reflexes (root reflex, a suck reflex, a swallow reflex and then protective reflexes like gag and coughing)
  • Liquid leaking from the mouth during eating
  • Anatomy of the mouth, tongue, lips, neck, etc.
  • Positioning during feeding
  • Family educational needs
  • Sleep and timing considerations

Oral motor assessment in babies

In older babies, you begin to see certain developments. Missing these milestones can indicate oral motor problems. These considerations should be addressed in occupational therapy oral motor assessments as babies grow:

  • Hands in the mouth in exploration and play- this is normal part of exploration and supports development of tongue, lips, cheek mobility
  • Positioning and seating (high chair positioning)
  • Neck, head, and upper body control against gravity
  • Motor coordination at age appropriate levels
  • Bite reflex
  • Mouthing toys, teethers, etc.
  • Making sounds with a variety of oral motor movements
  • Mimic facial expressions (open mouth, tongue out, etc.)
  • Gag reflex present
  • Accepting variety of baby food textures, flavors
  • Accepts foods from a baby spoon
  • Lip closure
  • Tongue mobility (thrusting tongue after initial spoon offerings is normal)
  • Transverse tongue reflex- The baby/child feels stimulation on the side that tongue and the tongue moves in that lateral direction- needed for swiping foods
  • Attempts or tries a variety of flavors, textures, and softer, larger foods

Oral motor assessment in toddlers-

During the toddler years, oral motor issues can present in drinking, feeding, and other areas. Consider these aspects in OT assessments:

  • Drinking from sippy cup/open cup
  • Drinking from a straw
  • Drinking a variety of textures and thicknesses (water, juice, thick or thin smoothies
  • Eating a variety of textures and thicknesses
  • Eating fluids mixed with solids (cereal, soups)
  • Biting foods from a larger piece of food
  • Moving food around within the mouth
  • Swiping the mouth with the tongue to clear the mouth
  • Chewing with rotational movements of the jaw
  • Begins to remove food from the lips with the tongue

Oral motor stimulation

We cover specific oral motor exercises designed to support the oral motor stimulation to move the lips, tongue, and jaw to bite, move, swipe, clear the mouth of food, and swallow food in our resource on oral motor exercises. However, below you will find strategies to provide oral motor stimulation to the mouth, lips, gums, and tongue.

Oral motor stimulation in occupational therapy centers around play in order to enable function. This focuses on independence with feeding with safe ability to bite food, clear food from the mouth with the tongue so that food can be swallowed.

Tongue Stimulation-

  • Use a mouth swab– to touch, swipe, tap and swab the tongue on the sides, at the tip, and along the length, avoiding the back of the tongue to avoid activating a gag reflex.
  • Use a vibrating toothbrush- to stimulate tongue movement on the sides. This can help the tongue with lateral movements.
  • Use a gloved finger- Put on a latex or non-latex glove and use a finger to tap the sides of the tongue. The glove can be worn by either the occupational therapist or the individual themselves.
  • Use a mirror- Move the tongue by mimicking movements and watching them in a mirror. You can even have the individual touch their tongue to a clean mirror surface. Play in front of a mirror alongside the child or in front of the child above the mirror so the child can look at the therapist’s face and check their movements in the mirror at the same time.
  • Tongue movement exercises- Use the tongue and mouth exercises included in our Deep Breathing Exercise pack for ideas.
  • Tongue sounds- Make clicking sounds with the tongue on the roof of the mouth. As the child/individual to copy the sounds.
  • Push the tongue into the cheeks of the mouth to copy motions. This can help with lateral sweep of the tongue to clear foods by increasing tongue range of motion.

Lip and Cheek Stimulation

  • Washcloth oral motor simulation- this occurs with a dry wash cloth and then a wet wash cloth by rubbing the lips and cheeks. Each area can be separated so they are addressed in isolation. Use a dry washcloth or wet washcloth to wipe the face, without food use. Use a warm or cold washcloth to wipe the face.
  • Making faces- Cheeks and lips can obtain heavy work, or proprioception by puffing up the cheeks, making fish lips, sealing the lips and blowing, blowing raspberries, copying facial expressions, etc. Play “Simon Says” with facial expressions. We have oral motor Simon Says Commands to share!
  • Food stimulation- Some foods (sweet, sour) are very alerting. These can be used as a frozen pop in the form of a lemonade pop, smoothie, or popsicle. Or, add fruits and frozen foods to a mesh bag that is sucked on.
  • Ice pops- Freeze an ice cube on a popsicle stick and use it as an alerting and stimulating tool to “wake up” the lips and cheeks.
  • Vibrating tools- Play with vibrating mouth toys and touch the face, mouth, lips, teeth in the way of a vibrating toothbrush (offering input through the jaw).
  • Wilbarger Brushing Protocol– Use prior to eating foods (contact a trained therapy professional)

Jaw Stimulation-

  • Vibrating toys- vibrating toys, chewing tools, or a vibrating toothbrush can offer oral motor stimulation through the jaw. This can be very alerting, so use with caution.
  • Chewing tools- biting on “chew toys” (described as heavy chewing therapy tools) or chewing tools that add heavy work through the teeth and jaws. This offers feedback to “wake up” the jaws.
Oral motor issues related to feeding in kids

    As you can see there is a lot of different areas that need to be assessed and addressed when it comes to oral motor concerns related to eating and drinking.       

  

 
 
 
 
 
 
 

Colleen Beck, OTR/L is an occupational therapist with 20+ years experience, graduating from the University of Pittsburgh in 2000. Colleen created The OT Toolbox to inspire therapists, teachers, and parents with easy and fun tools to help children thrive. As the creator, author, and owner of the website and its social media channels, Colleen strives to empower those serving kids of all levels and needs. Want to collaborate? Send an email to contact@theottoolbox.com.

What You Need to Know About Sensory Food Issues

Sensory food issues

Sight, smell, taste, and touch are some of the contributing factors to a child’s sensory food issues.  How it looks, smells, the consistency/texture of the food, and the way it feels on the fingers or utensils can make a child/learner feel uneasy, uncomfortable, and unwilling to try.  Children and older learners struggling with sensory issues with food, are often lacking a good variety of foods that contain proper nutrition for their health and development. 

Sensory touch is a huge piece of this; not only the texture of foods in the mouth but the “feel” of foods as we handle them and chew them.

Sensory food issues

sensory food Issues

There is a range when it comes to determining sensory eating disorders. From extreme food aversion to the simplest of sensory food preferences. We all have probably experienced some aspect of this, at one time or another.

Think about a food that you don’t prefer just because of the texture. Maybe it’s biting into a banana or a mushroom. Perhaps it’s chewing the stringiness of asparagus or celery. Does the sensory aspect of food textures like drinking smoothies or biting into a mushroom throw you off? There are many aspects of eating that are rooted in the senses.

We as OT practitioners know that a colorful plate of food is contains essential food groups and healthy eating choices to help a child blossom and thrive. Children and older learners who struggle with sensory food issues, often can not climb this hurdle for themselves without OT intervention. OT practitioners are experts in play-based therapy, and feeding therapy is no different. OT’s enjoy making eating fun while improving the sensory culprits that challenge a child’s success with feeding.

Oral Motor Vs. Sensory Food Aversions

As a side note, picky eating is not always a “sensory” issue. Sometimes there can be oral motor issues at play or other considerations.

We have a variety of resources on the website related to oral motor considerations as this can be a safety issue when it comes to oral motor development and “pushing” kids to try new foods. You’ll want to check out these oral motor resources if you are concerned or questioning a sensory aspect of feeding challenges or an oral motor issue:

It’s important to always seek out professional advice when it comes to feeding challenges in kids.

sensory food exposure and feeding therapy

The hierarchy of sensory exposure during feeding therapy, provides a good introduction and follow-through of steps to sequentially build sensory exposure to foods. The ultimate goal is being successful interacting or eating the non-preferred food. Eating and mealtime is a multi-sensory experience that children with sensory food challenges may have difficulty viewing in a positive way. Even the tolerance of the food in the same space is a successful step! 

Aside from clinical assessment, this Food Inventory Questionnaire can help the therapist, develop a proper treatment plan. It gathers important data about a child’s current preferences, so that likes and dislikes can be established, to begin food introduction and food chaining in feeding therapy.

Children use their sense of sight to look at their plate of food, surroundings, and those who are joining the mealtime experience

We’ve all looked at something and thought, ‘That is really gross…YUCK’! Children who have sensory food aversions are “grossed out” when they see some foods.  Along with “yuck”, comes gagging, coughing, face squinching, head-turning, hands to mouth, plate pushing, and even covering the food to hide it. 

In their state of fight or flight, learners will try anything to avoid looking at the food, let alone eating it. Read more about this aspect in our resource on the limbic system.

Sometimes children get overwhelmed when they look at a plate, especially if the plate is packed to the edges with food, if the food on the plate is touching, or they do not see anything they like. How can you help kids who struggle with a visual aversion to food?

Visual Tips and Tricks

One strategy to support sensory food needs is to use the power of the visual sense. This can be explained in more detail below. We’ll cover several areas:

  1. Food separation on the plate
  2. Fun foods and fun presentations
  3. Motivating snack mats or plates

Food Separation

This is an easy strategy to implement by simply separating the food with a good distance between each food choice, so that food does not touch. A muffin tray is another excellent way to keep food from touching.

Another fun idea is to turn mealtime into a game, to provide a little distraction from the actual act of eating. Hopefully the activity will make eating a more positive experience, rather than a dreaded one.

Take a look at a few products available for this technique, that provide food separation by design (Amazon affiliate links below):

  • Dinner Winner Food Game Tray is a food tray that is designed like a board game and the child travels the food sections to get to the end where a special treat awaits
  • SpinMeal Plate is a plate where an arrow is in the center of the sectioned food plate. The child spins the arrow to choose the food compartment to try
  • Divided Kids Dinner Plate is a colorful portioned plate that contains encouraging words to provide ongoing motivation
  • Sectioned Dinnerware Plate is a game board where a child gains points with each section of food trialed or eaten
  • Divided Lunch Trays are simple divided trays that are solid in color, making them less visually distracting for children who may become overwhelmed with all of the visual clutter of the other game trays and plates

Smaller Plate and Utensil – Using a smaller plate with less food, helps the child feel less visually overwhelmed with how much they will have to eat. Using a smaller spoon or fork to scoop or pierce, can give the child a better feeling of manageable food amounts. Read more about tips and strategies to help kids learn to hold a spoon and fork.

Fun Food

Make food look more fun and less ‘foodie,’ as you create images and scenes with the food, making it more enticing to trial. Who doesn’t want to eat rainbow snacks or how about Flower snacks? These treats are fun to look at, and motivating to eat. 

Food Art Snack Mats – Try using fun snack mats you print and laminate. This can be used as a fun visual background while eating. 

It’s easy to get the kids involved in making a variety of food art snack mats, and games to support mealtime with kids. 

Children use their olfactory sense to smell the flavors of the food, both while it is cooking and on their plate

“Shuwee, that stinks!” Yep, we’ve all said it about something. The neighborhood skunk, the car exhaust in front of us, the litter box, and even the spices in the kitchen.

Children who have olfactory sensitivity smell food odor at a much higher level of intensity. They pinch their noses, turn their heads, try and leave the table, or vomit/gag in response to the smell. 

Check out the strategies below to help desensitize a child to the food smell. Slowly introduce smells of varied scents from light to heavy, to build desensitization more easily. 

Olfactory Tips and Tricks

Essential Oil Set-up – Set up the space for eating by using a calming scent of essential oil that is easily tolerated by the child in the eating area. Essential oils can calm anxiety related to eating, and desenstize the system to the food odors. Hopefully this will make a child more tolerant to the less preferred smells

Coffee Bean Support – Use a few coffee beans near meals, as the coffee scent can help neutralize the smell of some foods. If your learner has an aversion to coffee, you might need to try a different neutralizer

Cold vs. Hot – Naturally, cold foods do not smell as strongly as warm/hot foods. If colder foods can be tolerated by the child, try serving foods cooler, to reduce the food odor naturally.

Kitchen and Dining Modification

Addressing environmental considerations can have a big impact. Try these strategies:

  • Consider moving mealtime experiences outdoors.
  • Remove the child from the kitchen/dining area as some of the cooking smells from hot foods will linger for longer periods of time, within these rooms.
  • Open a window or patio door, or using a fan when cooking, to help reduce the amount of odor emitted into the room. This can lessen the aversion to smells.

Meal Prep Warning – Before cooking, warn the child that cooking will begin soon, as this can help the child prepare their sensory system mealtime, as they use some of their learned coping techniques. 

Cover the Smells – If serving food on the tabletop for the entire family, try covering each dish with a napkin to limit the amount of odor from each of the served foods. 

olfactory play

Scented play activitiesScented sensory bins, scented play dough, or other scented play activities can inspire calming or alerting scented play.

Smell Bottles or Sniffing Jars – Create some fun sensory sniffing jars with varied smells to help the child start processing a variety of smells. These jars are created by placing a variety of scented objects into small containers with holes in the lid of the jar. The smell will rise out, and the child can sniff at manageable distances. The larger the hole, the more the scent is dispersed. Some ideas include cinnamon, coffee, coconut, lemon, lavender, peppermint, etc. Create these smell jars to play with, by stacking and matching to the card images of the scents, or play a fun guessing game, by smelling and guessing what scent it is, then matching the jar to the card image. 

Children use their sense of taste to determine if they like the flavor of a food

Lip grimacing, lip tucking, and hiding lips with a hand are some of the actions a child with sensory food issues will make when presented with food toward their lips.

There are a set of steps feeding therapists use to help a child eventually eat a non-preferred food.

  1. First, the food is brought to the lips much like kissing.
  2. Then they lick the food.
  3. Make teeth marks in the food.
  4. Take a bite of the food.
  5. Finally, chew and swallow the food.

These are not all of the steps needed to approach gustatory aversion to food, and it’s important to acknowledge that each individual with sensory food issues will present differently.

Each of these steps will build the skills the child needs to successfully try new foods, eventually adding them to their diet.

Importantly, being a cheerleader for your child with sensory food issues or struggles is important. Try these tips for supporting small successes:

  • Be patient, and celebrate each step as a success.
  • Give a high five, a hug, or a cheer.
  • Focus on whatever motivates the child to keep trying! 

Gustatory Tips and Tricks

Some of these tips may help with the gustatory, or sense of taste as a strategy and powerful component in supporting sensory eating needs:

Sauce and Condiment Support – Use sauces or condiments as a support tool during feeding sessions, to provide a muted or masked taste of a trial food, to build acceptance of the food within the child’s diet. Broccoli with ketchup still has all the nutrients of this vegetable.

Spice Limits – Think about the spices used when cooking food, and try to limit some spices that are non-preferred, until the child can accept small amounts, that can be increased over time.

Children use their sense of touch to understand their food

“That feels gross! It’s mushy, slippery, sticky, hard, bumpy, etc.” There are many ways that texture food aversions can develop in children. The way they imagine it feels, the way it actually feels, or the way it feels transporting to the mouth. The best way to approach textural aversions is to introduce textures in a less threatening way – by play! 

Always remember when playing with food that the goal is not just to eat, but to interact and build positive associations with food, and become more comfortable with the various aspects of it including texture, shape, color, smell, etc. Let the journey begin with the hands and the eyes. 

Tactile Tips and Tricks

Sensory bins – They are a classic OT tool.

  • Make sensory bins use cooked foods too! Remember if the food is cold, the smell is less intense, or many times there is no odor at all. Try using cooked spaghetti, pasta, rice, or veggies, some crumbled-up toasted bread, bagels, or rice cakes as a sensory bin. Note: Always be cautious when using cooked foods, making it a habit to throw out after play, for safety.
  • Another idea is to make sensory bins containing play items that look like the foods a child has an aversion to. Simulated cooked spaghetti could be a yarn bin, toasted bread could be a cut-up sponge bin, and whipped cream could be a shaving cream or cotton ball bin. In addition, use the typical food items like dry beans, dry rice, dry pasta, graham cracker crumbs, oats, and water, as sensory bins for exploration.
  • Make the bins more appealing by tossing in some fun toys, burying them, use fun voices to talk for the toys, or use a Mr. Munchie Man ball to support fun playtime. Kids love to see Mr. Munchie Man try smelling, kissing, and eating some of the textured items in the bins.
  • Model play, by getting your hands into the bin, getting dirty to show the children this is a fun activity.
  • Another strategy is to give the child utensils to poke around in the texture bins if they are resistant to placing their hands inside. Eventually work toward using smaller utensils and tongs until they become more tolerant and willing to dig in with their fingers and hands.
  • Messy eating is another strategy that can work, too.

Food Presentation Changes

Think about the different ways you can change the texture of foods that children dislike, or change the presentation of the food, by adding something or making it differently.

Some ideas include:

  • Presenting toasted bread instead of soft bread
  • Yogurt with granola instead of plain yogurt
  • Roasted or fried potatoes instead of mashed potatoes
  • Banana slices with granola instead of plain banana slices
  • Sliced or chunked apple pieces instead of applesauce
  • Shredded meat instead of whole
  • Shredded cheese instead of sliced or chunked cheese
  • Covering pancakes with apple butter instead of syrup

Food Art Snack Mats

Grab a few food art snack mats and turn food into playtime fun while exploring textures. 

  • Make a Face using fruit pieces on a laminated placemat
  • Cut out circles to create a space for a plate, cup, and on a paper placemat. Then, add paper forks and spoons. Laminate to create a reusable placemat the kids can decorate.

Non-edible Sensory Recipes

Check out these fun sensory dough recipes, and have fun making something that children can play, with while exploring a variety of textures. These recipes are simple to follow, and make the perfect tactile experience, while also providing ownership of the end product, as they make it themselves.

The recipes include play dough, Oobleck slime, Flubber, kinetic sand, silly putty, and cloud dough.  A variety of textures to explore and digital download includes learning activities related to each recipe too! 

Last Thoughts

A few quick last thoughts on making the journey to mealtime a success for each child. When sensory food issues and challenges arise, keep these things in mind:

  • Always honor the child’s responses to food interactions and be sensitive to their feelings.
  • Never force a child to participate in actual eating of food until they are ready. You can nudge, but never make it forceful.
  • Give the child as much control as possible by letting them make some choices, like what spoon or plate to use, or what beverage they want to drink. Try allowing them to pick their placemat or table cloth for setting their meal.
  • Give them choices that are sufficient enough for their needs, but not overwhelming.
  • Understand and accept that helping a child overcome food sensory aversions will take time and effort as your support each step in their journey. 
  • Keep practicing, and keep working. Even the smallest of steps forward are still a success, and they should be celebrated!

This sensory food issues post is part of a feeding series. Be sure to check out the other posts available on this topic. The Sensory Lifestyle Handbook is a great resource to understanding sensory struggles.

The Sensory Lifestyle Handbook walks you through sensory processing information, each step of creating a meaningful and motivating sensory diet, that is guided by the individual’s personal interests and preferences.

The Sensory Lifestyle Handbook is not just about creating a sensory diet to meet sensory processing needs. This handbook is your key to creating an active and thriving lifestyle based on a deep understanding of sensory processing.

Strategies for Sensory food aversions

Sensory Food Aversion Handout

When sensory food aversion is a real struggle in a household, everyone in the home can be affected. Educating on how to support an individual with sensory food aversions is key.

We’ve created a free handout that does just that. This printable sensory food aversion handout covers the strategies addressed in this blog post as an educational resource. While it’s not intended as a replacement for therapy, the handout covers strategies and supports that can be used along with therapy services and individualized interventions.

Therapy professionals can use this handout as an educational tool to support the needs of families.

Print off this sensory food strategies handout and add the resource to your therapy toolbox.

  1. Enter your email address into the form below.
  2. Check your inbox for the email containing the printable.
  3. Print it off and go!

Or, OT Toolbox Member’s Club members can access this printable resource inside the Member’s Club. Log into your account and head to Educational Handouts. You’ll find the printable there.

Free Handout: Strategies for Sensory Issues with Foods

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    Regina Allen

    Regina Parsons-Allen is a school-based certified occupational therapy assistant. She has a pediatrics practice area of emphasis from the NBCOT. She graduated from the OTA program at Caldwell Community College and Technical Institute in Hudson, North Carolina with an A.A.S degree in occupational therapy assistant. She has been practicing occupational therapy in the same school district for 20 years. She loves her children, husband, OT, working with children and teaching Sunday school. She is passionate about engaging, empowering, and enabling children to reach their maximum potential in ALL of their occupations as well assuring them that God loves them!

    Note: while this post refers to children, people of all ages and stages suffer from sensory food issues. Many of this information pertains to any age, and can be used for different age groups.