Therapy for Picky Eaters

food therapy for extremely picky eaters

In this blog post, we are covering therapy for picky eaters. Occupational therapists and speech therapy practitioners often cover extremely picky eating in therapy sessions, but how do they know where to begin with food therapy? Let’s cover specifically how to help extremely picky eaters, food for picky eaters, and therapy suggestions for extremely picky picky eating disorder.

Therapy for Picky Eaters

Fifty years ago, feeding therapy this would not have been a popular topic. Children ate what was provided, like it or not.  Sometimes parents would spare the child and leave the offending objects off of the plate. More often than not, children over the age of four were expected to eat what everyone else was eating.

Fast forward to 2022. There has been a huge rise in allergies, picky eaters, and problem feeders. How to help extremely picky eaters  has become the forefront of many occupational therapy sessions and referrals.

There has been a marked rise in food sensitivity (gluten intolerance, lactose intolerance) or allergies to certain foods.  This goes hand in hand with the rise of anxiety, illness, ADHD, autism, and poor immune response. 

Picky Eater List

There is a difference between oral motor skills that impact feeding abilities and a child’s picky eating. Foods that make the “picky eater’s list” might include certain food texture issues, food mixtures, food sensory issues like crunchy foods, and even foods that require utensils. 

A short list of some foods that are not on the plate of extremely picky eaters might include:

  • Sandwiches
  • Rice
  • Chicken breast or other meats
  • Carrots
  • Cheese
  • Sauces
  • Vegetables
  • Fruits

Obviously this is a short list and any number of foods, food types can be on a picky eater list. Any other number of foods or food combinations

Looking at this list, you can see the limitations in nutrients, vitamins, proteins, and brain-building foods that are missing from the plate of an extremely picky eater.

It is not productive to get stuck in the “why is my child a picky eater”, but move forward to “what can I do about picky eating”.  I am not just an experienced feeding therapist, I too had two picky eaters who survived on 3-4 different foods in their second and third year of development.  

In order to help my daughters, I had to remove my thoughts impacting how I approached tackling that picky eater list for each child. That includes putting aside parenting/worry/anxiety/they’re starving persona, and put on my therapist hat.  I am happy to report they are thriving adults who eat a huge variety of foods!

 NOTE*The term, “learner” is used throughout this post for readability and inclusion. Not all picky eaters are children. This information is relevant for students, patients, clients, preschoolers, kids/children of all ages and stages or whomever could benefit from these resources. The term “they” is used instead of he/she to be inclusive.

 How to help extremely picky eaters 

To learn how to help extremely picky eaters, it is important to define it first.  

Picky eating is different from problem feeding.  Often, but not always, extremely picky eating is actually a problem feeding disorder. This has recently been renamed Avoidant Restrictive Food Intake Disorder ARFID.  ARFID is not classified with eating disorders such as anorexia and bulimia, as persons with ARFID or problem feeding do not restrict their intake due to body image.

The term picky eating includes:

  • Selective eating habits
  • Eats 10-20 different foods (preferred foods)
  • Will often eat more if hungry
  • Not missing entire food groups
  • Can often be bribed or rewarded for good eating
  • Can be distracted into eating
  • Adds new foods to their diet

Problem feeding (extremely picky eating) refers to:

  • Refusal to eat
  • Rigid eating habits (no food touching, specific brand, same plate, cut a certain way)
  • Eats less than 10 different foods
  • Will starve before they eat unwanted foods
  • Missing entire food groups 
  • Behavioral reactions: gagging, vomiting, crying, anxiety, refusal to sit at the table
  • Increased sensitivity to the taste and/or texture of foods
  • No amount of rewards, bribing, punishing will magically make this go away
  • Does not recognize hunger
  • Food jags, will lose foods once eaten regularly

What is the difference between picky eating and problem feeding?                

The picky eater will survive.  They are likely to consume at least one meat, fruit, and vegetable and a bunch of carbs.  

Continue to put out expected foods on the plate and encourage tasting of new foods.  The problem feeder on the other hand, is not consuming enough calories, or getting the right nutrition.  

A person surviving on four foods often gets tired of one of them, eating only three foods now.  This is more of a dire situation and the treatment is complicated.

If you have a problem feeder, seek treatment from a therapist who is certified or has attended classes in feeding therapy.  There is a lot that can go wrong working with problem feeders.

The Sequential Oral Sensory course, Beckman Oral Motor Therapy, and Mealtime Miseries are popular courses. Having this information can help in identifying whether extremely picky eating is related to sensory or oral motor difficulties.

Therapy for Extremely Picky Eating

After viewing the list, if you feel the learner is more of a picky eater, there are several strategies that can help.

Following a feeding evaluation, feeding therapy can begin. Start a structured feeding problem including the following:

1. Feeding Therapy Interview

Interview the caregiver to determine the following:       

  • What foods the learner eats – a specific list will determine texture, variety, color, or patterns. Are all the foods crunchy? Are they all brown?
  • How many foods the learner eats – less than 10 is a problem, 10-15 is picky, and above 20 is average. Count two different cookies as two items, two cereals as two items.
  • Medical history – Is there a history of reflux, G-tube, or NG-tube, swallowing issues?
  • Time frame for eating – A typical meal should last 20-30 minutes for a child.
  • Where the learner eats – Does the learner eat at the table or in front of the television? Do they run around the room catching a bite here and there?
  • Behavioral reactions during meal times – Does the child flee the table? Turn their whole body away from the food, vomit, cry, refuse to open their mouth, gag, spit out food?

Record information from caregivers and look for clues to feeding issues, other than the exhibited behavior. The person may have a history of reflux that makes eating very uncomfortable.  They may have been verbally abused and shamed during mealtime, making eating an unpleasant experience. Perhaps the child has never had structure or routine during meal time, thus not making eating a priority. 

2. Planning for Feeding therapy

Start treatment planning                

Begin with the provided list of preferred foods to determine what foods to try first.  A Food Inventory Questionnaire can be used for this step.

If the learner eats: crackers, pancakes, waffles, bread, and dry cereal, they may have a preference for white/brown foods that are dry. Some are crunchy foods and some are soft foods, but all are dry. 

The next in order would be another dry brown food such as toast, bagel, cookie, or different type of cracker. 

Once the child tolerates more brown dry foods the next texture in the same color family would be a banana or plain macaroni. 

For the learner who eats only purees or smooth foods like pudding, yogurt, and baby food, the next step would be to try different flavors of yogurt or pudding. For a learner who only eats smooth foods, it is important not to vary the texture yet. After the child tolerates this texture, then a trial of applesauce may work.

Adding flavor choices and additional nutrients can be found in sauces or dips. While this can be a source of refusal for some kids, others prefer dips such as ketchup or ranch dressing.

Take a look at what the individual is gaining from these dips. Both can be high in sodium and that salt intake is preferred. Can you offer other foods to dip into the preferred choices?

Think about other similar options that may offer a similar sensory input through texture or taste:

  • butter for pasta rather than sauces
  • pizza sauce in place of ketchup

3. Feeding Therapy Treatment session              

Ask the learner or their caregiver to provide two favored foods and 2-3 non favored foods. Having preferred foods decreases anxiety as  the child is not presented with a plate of non favored foods.  

It is important for the learner/caregiver to provide the food.  Possible allergic reactions are diminished, as the caregiver is more aware of the learner’s diet. There may be cultural or dietary foods that the family prefers.

It doesn’t do any good for the therapist to work for weeks on waffles and applesauce, if the family does not offer these foods.

Food presentation – Present all foods on the plate in small portions, or a choice of two options with small bites of each. Avoid huge piles of non-preferred food, as it increases anxiety or aversion.

Divided plates help ease anxiety, as do small portions. It can help to present the food as snacks, using a snack plate or small tea plate.

Food exploration- Start to encourage eating, or at least food exploration.  Have the learner look at the food, touch the food, touch it to their face, give a kiss, give a lick, take a bite, chew, and swallow. This resource on sensory touch can offer more information and strategies to support tactile exploration.

There are 27 steps to eating from being in the same room as the food, to chewing and swallowing it.  This makes learning to eat new foods challenging. 

Offer food options- Allow the child to touch foods or use their fingertips to pick up and eat or taste the foods. In some cases, muscles and coordination are not appropriate for utensil use, limiting options.

Read about suggestions to improve how to hold a spoon and fork.

Offer various food temperatures. Consider the sensory input offered by cooked carrots vs. raw carrots. 

Offer various food cuts. Consider the amount of force needed to bite baby carrots vs. shredded carrots.

Food Therapy Progression

Food therapy interventions are about progressing through with small incremental changes to food offerings with observation and food challenges. Some food therapy goal banks are included below.

Learner is able to:

  1. Be in the same room as the food, then in the same area as the food.
  2. Sit near the food, then in front of the food without turning away.
  3. Look at food, touch the non preferred item, smell the food.
  4. Touch  the food to face, then lips, then give it a kiss.
  5. Lick the food, take a bite and spit it out, chew the food with the option to take it out.

While presenting and working on the feeding portion, observe for signs of oral motor issues that might indicate oral motor development considerations.

  • Does the learner chew from side to side or munch up and down?
  • Do they have good lip closure?
  • Do they have an intense gag reflex?
  • Can they move the food around effectively?
  • Can they bite into the food?

4. Carryover of Therapy for Picky Eaters

The ultimate goal is to carryover skills achieved in therapy sessions into a functional environment. Discuss techniques with caregivers and encourage them to try the same foods later in the day.

Remind them to be calm and not emotional during feeding time. The goal is to have fun with food and find mealtime enjoyable.

For more information on how to help extremely picky eaters, I have also published a helpful resource book (Amazon affiliate link) Seeing your Home and Community with Sensory Eyes for to understand different environments that may be impacting the eating habits of your child/clients, including the cafeteria, kitchen, restaurants, and more.  

Feeding and toileting are two of the most frustrating, anxiety producing stages of childhood. Children start to exert their free will at this stage and can no longer be forced to do certain things.

Encourage parents, educate yourself on this topic, and spread the word, so problem feeding does not continue to rise along with other scary diagnoses. 

This post is part of a series on feeding disorders/picky eating. Other resources you will find helpful include:

Victoria Wood

Victoria Wood, OTR/L has been providing Occupational Therapy treatment in pediatrics for more than 25 years. She has practiced in hospital settings (inpatient, outpatient, NICU, PICU), school systems, and outpatient clinics in several states. She has treated hundreds of children with various sensory processing dysfunction in the areas of behavior, gross/fine motor skills, social skills and self-care. Ms. Wood has also been a featured speaker at seminars, webinars, and school staff development training. She is the author of Seeing your Home and Community with Sensory Eyes.

How to Hold a Spoon and Fork

How to hold a fork and spoon

Teaching a child how to hold a spoon and scoop food requires several motor skills that must be developed before a toddler can use utensils themselves. Even older children struggle with holding a spoon and scooping food to feed themselves. Here, we’re covering sensory motor skills needed to hold a spoon, fork, knife, and other utensils. You’ll also find some creative activities and play ideas to develop the underlying skills that play into using utensils.

How to hold a fork and spoon
How to hold a fork and spoon with efficient grasp patterns.

Note that these strategies and skill areas are needed across the lifespan when it comes to self-feeding. Older children and even adults who may have had a physical or cognitive impairment can benefit from addressing the underlying skill areas needed for using utensils. No matter the age, noting how an individual holds a spoon and fork is part of a comprehensive feeding evaluation.

how to hold spoon and fork

Before we get to the skills in play when holding a spoon or using a fork, let’s cover the specifics on how to hold these utensils. Why? Because often, we see older children who hold a spoon with a gross grasp or hold a fork with the whole hand. These grasp patterns can impact functional performance, but can also be a cause of concern for parents.

Note that the way an individual holds a spoon or holds a fork can differ when adaptive equipment for eating is used.

How to hold a spoon
How to hold a spoon.

how to hold a spoon

To hold a spoon, one needs to grasp the utensil with their dominant hand. The spoon is placed along the lateral edge of the middle finger or pad of the middle finger. The pointer or index finger typically rests over the top of the neck of the spoon, and guides movements when scooping. The thumb rests and stabilizes the flat handle of the spoon on the top, above the pointer finger in a modified lateral key grasp. The scoop of the spoon is pointing out toward the direction the thumb points, and the handle is above the thumb web space. In this position, one can scoop with refined movements and graded precision using the pad of the thumb on the flat part of the spoon handle. When the spoon is properly placed in the hand, the wrist is slightly pronated and slightly flexed.

You can see from the image below that there are many different grasp patterns used when holding a spoon, which progress as the child develops more refined fine motor skills. The most efficient grasp pattern is the “adult grip”, however, the other grasp patterns are typically part of a progression as the toddler or young child gains experience with eating with a spoon.

Using a spoon is likely one of the first functional tools that a small child has experience with, and while messy eating will ensue, it is important to allow the baby or toddler experience with holding and manipulating a spoon, even if they are not getting actual food into their mouth at first.

Grasp patterns for holding a spoon
Grasp patterns for holding a spoon.
No source was found for this image, may be subject to copyright

Inefficient grasp on a spoon- When the handle end of the spoon is UNDER the thumb web space, the grasp moves into a poor position for function and accuracy of scooping. In this case, the hand moves into a gross grasp pattern, and in order to gain motor control with graded precision, the elbow tends to pop out as the shoulder abducts. In this poor functional grasp pattern, you’ll see the wrist fully supinated.

Activities to move from an inefficient grasp pattern to an efficient grasp pattern include PLAY:

How to hold a fork
How to hold a fork.

how to hold a fork

Next, let’s cover the proper grasp pattern required to effectively hold a fork. Note that there are different ways to hold a fork, depending on location, no one way of these different style being better or worse for functional performance to hold and use a fork to stab and eat food.

To hold a fork, the fork is held in the dominant hand much like a pencil is held. The thumb stabilizes the narrow part of the fork handle, or the neck of the fork. This area is located above the prongs, or tines of the fork. The neck of the fork rests on the lateral side of the middle finger or the pad of the middle finger.

Like holding a spoon, the end of the fork is above the back of the hand, and not under the thumb web space into the palm.

The wrist of the hand should be slightly pronated and slightly flexed.

Note that when holding a fork to scoop food, a different grasp pattern is used than when using a fork to stab food, and still another grasp pattern is used to stabilize food when using a knife to cut.

To stab food with a fork, the fork rotates in the hand and skills of in-hand manipulation are used.

To stabilize food with a fork, in order to hold food stabile so a knife can cut the food item, the fork continues to rotate within the hand using in-hand manipulation, but the addition of finger isolation of the index finger is used to hold the fork steady.

Inefficient grasp on a fork– When the end of the fork handle is under the palm, the hand tends to pull into a gross grasp on the fork, which is a more primitive grasp pattern, and is less functional for refined and graded movements. Similar to the motions used with a spoon held in this manner, a fork held in a gross grasp will include elbow and shoulder.

Much like using a spoon, progression from inefficient grasp patterns on a fork is developmental and requires practice. Allowing kids to use and hold a fork with verbal and visual prompts is helpful. Other fine motor and eye-hand coordination tasks will support development from inefficient grasp patterns when holding a fork to more efficient and refined motor skills:

Prerequisites to hold a spoon and fork

Before a child can use fine motor tools such as a spoon, fork, knife and other self-care tools (hair brush, toothbrush, pencil, scissors…) independently, there are certain physical, cognitive, and emotional prerequisites that must fall into place.

These self-care skills include many of the same sensory motor components, so in this blog post, we’re covering primarily the skills needed to hold a spoon and fork.

Toddlers and young preschoolers that sit at the table, probably have taken notice of how adults and older children at the table eat. This is actually part of the developmental process. When sitting at a table, a baby and toddler is observing and noticing how older siblings and parents use forks to stab food, spoons to scoop, and knives to cut.

Toddlers often want to take part in the action!

Using a spoon and fork during the Toddler years is a natural development of self-awareness and self-control.  Using utensils is part of that progression of feeding developmental milestones that children go through. A child becomes more aware of the skills that they are developing and that they can assert their own independence. 

Likewise, using a spoon to eat at first can lead to messy eating with young children, and that’s totally normally, developmentally.

But, before these areas of independence arise, there are certain prerequisites that need to be in place. Using tools in self-feeding, brushing one’s own teeth, using a knife, crayon, pencil, or other tool requires development in a few areas. 

Speaking of using crayons to develop motor skills, these crayons for toddlers support fine motor development and coordination skills through play.

 

Prerequisites that are necessary for kids (or adults!) to effectively and efficiently use tools in fine motor and self-care tasks, like scissor use, handwriting, hair brushing, self-feeding, tooth brushing, and more.  From an Occupational Therapist.

This post contains affiliate links.

Skills Needed to Hold a spoon and fork

When you take a look at the motor breakdown of using a spoon and fork, there are several components you’ll see in action:

  • Posture
  • Grasp Development
  • Hand Preference
  • Cognition
  • Attention
  • Eye-hand coordination
  • Somatosensory experience
  • And even play!

Let’s cover each of these areas needed to hold a spoon and fork in more detail:

  • Posture- When using a tool like a fork, pencil, scissors, toothbrush, paint brush, knife…postural control is essential.  Like anything else, it all starts at the center and at the body.  You can’s use your hands in fine motor play activities if your upper body is slumped or slouched.  If postural support is the issue, work on getting into a better sitting position. Speak to an Occupational Therapist for individualized assessment and recommendations.                   
  • Grasp Development- For using tools, a child needs prehension skills and  precision skills, including grasp, release, and the ability to stabilize their arm and write while moving the hand.  Sometimes a pinch or required muscle movement is too much for an unstable arm/wrist and that required muscle effort makes the upper body slouch.  Start over with posturing is this happens.
  • Hand dominance–  A true hand dominance doesn’t typically become established until 5-6 years.  And that is a good thing!  A child’s body is developing strength, balance, muscle tone, and sensorimotor abilities at an even and symmetrical rate in the early years.  We want that to happen!  If a very strong preference of dominance is noticed at an early age, ask your pediatrician or occupational therapist for assessment of asymmetry or delay.
  • Cognitive prerequisites– Appropriate ability to follow simple directions is a must in order for use of tools in typical ways.  Sure, a fork makes a great hair brush.  A spoon is an excellent drumstick. But, inappropriate use of utensils can be dangerous.
  • Attentional Prerequisites– Appropriate attention span is needed for using tools in functional tasks. This blog post covers more on attention needed during meals.
  • Constructive play– What? A child needs functional play in order to use a pencil? Yep!  Building with blocks, combining toys, and pretending provides the base of fine motor development, skilled use, strength, imagination, and creativity that is needed to problem solve and use tools appropriately.
  • Eye Hand Coordination– More play!  Catch a ball and use crayons to establish the base of hand eye coordination needed for skilled maneuvering of tools to the mouth, paper, hair, or teeth.
  • Somatosensory Experience– Playing and experiencing the senses in typical every day activities are essential for the child to build on their awareness of textures, weights, manipulating objects, and sizes.

Given all of these areas that a child must have in place before showing success with tools in functional tasks, it’s important to work on certain areas.

Below, you’ll find a great printable resource that covers all of these skill areas that are needed for using a spoon and fork. This is a great handout to use especially when working with families of young children who are learning to hold a spoon and fork.

You can enter your email address into the form below and access this printable handout, or The OT Toolbox Member’s Club members can log into their accounts and access the handout in the Educational Handouts Toolbox area.

Prerequisites that are necessary for kids (or adults!) to effectively and efficiently use tools in fine motor and self-care tasks, like scissor use, handwriting, hair brushing, self-feeding, tooth brushing, and more.  From an Occupational Therapist.

Scooping food with a spoon

Teaching kids how to hold a spoon is the first step, but then actually scooping food, getting the food to the mouth, clearing the food from the spoon, and then repeating the process is part of the functional task of eating.

Remember that eating is a developmental process, and that this is another occupation in which practice is key to functional performance!

To improve use with a spoon and fork (and then spoon, fork, and knife!), it’s important to have various opportunities for practice.

Provide opportunities to use tools like spoons in scooping items.  You’ll find more information on the topic of scooping in our blog post on scooping and pouring.

These black beans are a great way to practice tool use and all of the skills needed in managing tools.  See the bottom of this post for more ideas.

Be sure to provide your little one with lots of opportunities to use tools in activities and play!

Related activities that you will love for teaching kids to use tools:

  • Sight Word Scoop– this scooping activity encourages users to develop the eye-hand coordination needed to use a spoon to scoop an object in a liquid, much like scooping the remaining cereals in a bowl of milk, or scooping food from a soup broth.
  • Toddler Visual Motor Scoop (Ping Pong balls)– This activity is another great way to teach toddlers to use a spoon, using a large and bright object with high visual contrast.
  • Invitation to Scoop and Pour– In this activity users can use a spoon with graded precision and refined movements to scoop grains of corn which can be a great way to practice motor skills to hold a spoon.
  • Field Corn Sensory Bin– Another activity using spoons to scoop field corn, this activity offers proprioceptive feedback through the joints and muscles of the hand, wrist, elbow, and shoulder.
  • Moon Dough Scooping– In this activity, users use a spoon to scoop and pick up a moist and dry material. This can be a great way to practice using a spoon with different materials.
  • Scooping Ice– Using a spoon to pick up ice is a fun way to practice using a spoon with a different material that also offers precision and refinement in using a spoon or scoop.
  • Relaxing Lavender Water Bin– Kids love this sensory bin, but therapists love the functionality! Use a spoon to pick up small items in a liquid, developing eye-hand coordination skills with sensory benefits.
  • Invitation to Scoop, Pour, Transfer Nuts– Use a spoon to pick up nuts with a fun sensory activity that offers feedback with movement.
  • Scooping Dyed Alphabet pasta– Kids can pick up dry pasta with a spoon and practice motor skills.
  • (Amazon affiliate link) Learning Resources Handy Scoopers are colorful and bright and a great way to practice the prerequisites for tool use in many ways.
How to hold a fork and spoon handout
Get this free handout on skills needed to hold a fork and spoon below or in The OT Toolbox Member’s Club

Free Handout- Skills Needed to Hold a Spoon and Fork

Want a printable handout of the skills kids need to hold a spoon and fork? Working with families on teaching kids how to hold a fork and spoon and need actionable tips and strategies in a handout format?

You can enter your email address into the form below and access this printable handout, or The OT Toolbox Member’s Club members can log into their accounts and access the handout in the Educational Handouts Toolbox area.

Free Handout: Using a Spoon and Fork

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    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.

    Feeding Developmental Milestones

    feeding developmental milestones

    Below, you will find resources on feeding developmental milestones and information on development of bilateral coordination that are needed for the feeding skills to use both hands together in a coordinated manner. These bilateral coordination milestones are needed for independent feeding skills, so let’s break this down.

    Development of bilateral coordination skills is necessary for improved self-feeding in toddlers and improves through the childhood years. Independence with feeding skills is an important part of child development!

    Feeding developmental milestones in kids

    Bilateral Coordination Development

    When we talk about bilateral coordination development, we can also mean bilateral integration. Typically, bilateral coordination skills refer to the physical sensory motor use of both sides of the body in a coordinated and fluid manner.

    However, bilateral coordination requires the overarching bilateral integration of the brain hemispheres and takes into consideration the ability to manage all of the functions listed above.

    In fact, there are three components of bilateral coordination and these play a role in feeding developmental milestones:

    • Symmetrical movements- picking up a bottle with both hands to drink
    • Reciprocal movements- Using one hand to pick up food and another to pick up food the next time; we see this with babies and toddlers especially
    • Dominant hand/supporting hand movements- Using a knife to stabilize the food and the knife to stab the food. Or, holding a bowl with the supporting hand and the dominant hand to scoop the food from a bowl

    Independence with feeding progresses from symmetrical movements to reciprocal movements, to dominant/supporting hand movements.

    One way to really take a look at the developmental progress of bilateral coordination skills is through the functional task of feeding using cutlery, or utensils like spoons, forks, and knives and drinking tools: cups, bottles, etc.

    When children learn to feed themselves and become more independent with self-feeding tool use with finger foods, utensils, or cups, development of bilateral coordination is one aspect that is necessary.

    When we think about self-feeding, problems can arise based on a variety of areas. Upper extremity coordination is one of those aspects that are evaluated and addressed when self-feeding difficulties are present.

    When thinking about development of self-feeding, consider the following issues related to bilateral coordination difficulty and try using some of the bilateral coordination activities based on development of bilateral coordination to improve feeding skills.

    Related: For several ideas to support bilateral coordination skills while indoors, try our list of Winter Bilateral Coordination Activities that kids will love!

    Discover typical development of bilateral coordination in feeding skills in kids, which are needed for improved independence in self-feeding.

    Bilateral Coordination Milestones

    Bilateral coordination development begins prior to birth, while in the womb with the physical movements felt by the mother. From there and immediately after birth, bilateral coordination milestones are achieved.

    Amazon affiliate links are included in this post.

    feeding developmental milestones

    Development of bilateral coordination in self-feeding depends greatly on the child’s developmental level. Below, we’ll go through feeding milestones by age.

    Development of feeding skills is just one skill that is a great way to to assess and analyze the development of bilateral coordination. Also, development of fine motor skills and visual motor skills have an impact on coordination of the hands in self-feeding.

    In one blog post, we covered the skills needed for independence with functional tools, including holding a spoon, scooping with spoons, using forks, and other tools like toothbrushes, hair brushes, etc. That is a good place to start with understanding all of the other areas of development that go into tasks like feeding.

    Throughout these ages, oral motor development plays a significant role in the manipulation of foods. Consider how these aspects of oral motor skills impact the developmental progression of feeding skills:

    • Rooting
    • Sucking
    • Swallowing
    • Gag reflex
    • Tongue movement
    • Jaw thrust
    • Jaw movements (moving jaw side to side to move food and movement of foods)
    • Lip closure during swallow phase of eating and drinking
    • Biting into foods
    • Tolerating different solid food and liquid consistencies

    Development of bilateral coordination occurs at every stage of childhood and can be observed through feeding abilities.

    Newborn Feeding Skills

    At the newborn stage, primitive reflexes dominate movements. In particular the rooting reflex supports feeding at this age.

    Babies aged 0-3 months will root, suckle, and swallow in feeding activities. This stage progresses as vision and motor control develop.

    Feeding milestones 4-6 months

    In this stage, development of coordination between the eyes and motor skills are just developing. The child explores with their eyes, hands, and mouth and will start to reach for objects purposely around four months. Accuracy of hand use is limited.

    Babies can be observed using both hands in play as they pick up objects in their line of sight. However, they typically will pick up items with the hand that is closest to the object or toy. 

    During this phase, the baby is spoon fed and when presented with a spoon, makes a suckling movement with lips and mouth. The baby will show a gag reflex at this age. With foods on a spoon, the baby will thrust their tongue out at the presence of foods and push the spoon away at times.

    Look for munching of the jaw, or movements in the jaw indicating a chewing pattern, even though the young child can not chew at this stage.

    Feeding Skills at 6-9 Months

    At this stage, the child is typically sitting up with or without support. The child’s hands are often times used in grasp with a clenched or a fist-like grasp.

    The child will begin to separate the thumb from the rest of the fingers to use a gross grasp on objects. Babies at this stage will typically place everything in their mouth, using both hands together in symmetry.

    The child will hold a bottle or cup with assistance, placing both hands on the cup/bottle, but are not able to hold the cup or bottle on their own.

    The gag reflex is still present but it is less sensitive to foods and utensils.

    The baby has a voluntary bite on soft foods, chew cookies, and baby teething foods. They will begin to hold those items independently using both hands together at their mouth.

    You will see a raking motion from the fingers, but this movement is typically not successful in picking up small foods like baby puff snacks. the baby can , however begin to pick up small food pieces using the thumb and the side of the pointer finger to grasp items (not a pincer grasp)

    Feeding Skills at 9-12 Months

    The child is able to sit upright without support and develops proximal stability, allowing for increased development of distal extremities.

    In this stage, babies are developing pincer grasp and thumb and finger opposition skills. This stage brings the ability to hold one object in each hand such as two blocks.

    The baby will be able to bring both hands together at the same time. Children will be able to begin finger feeding skills around 9 months as they bring dry cereal foods to their mouth with a scraping motion.

    Finger isolation on both hands begins as they poke foods and explore textures with their hands. Children will use both hands to smear food and bring soft foods such as wet foods like a cereal mix or applesauce to their mouth. The child will be able to hold a cup with both hands and bring it to their mouth.

    The child will start to hold a fork and spoon with a gross grasp, or a palmer grasp but without a dominant arm. At this stage, grasp of the spoon occurs with a palmer grasp. The child will not hold the bowl or plate with their non-assisting hand.

    You may see the baby begin to take longer sips from a straw while managing the liquid in their mouth to show a true drink. Similarly, with cup use, there is more drinking patterns as a result of the increased jaw control. However, at this age, these drinking skills are with an adult present to hold and remove the cup or straw. The bilateral coordination skills are not present in order to engage the hands either symmetrical coordination or as a dominant hand/supporting hand along with the drinking aspect.

    You will start to see more controlled use of the thumb and pointer finger in a true pincer grasp to pick up foods. This occurs between the tip of the thumb and the pointer fingers. The baby at this age can finger feed themselves.

    Feeding Skills at 12-15 Months

    In this stage, the child begins to dip their spoon into foods. They will have more accuracy with dipping as opposed to scooping foods.

    The spoon is held with a digital grasp and the child will likely switch hands while holding the spoon. The child will lift and drink from a cup with one hand.

    As toddlers progress in development, they will begin to establish a dominant hand and crossing midline. This ability to utilize a dominant hand and a non-dominant hand in activities indicates a maturation of the brain and lateralization in functional tasks, which is very important for motor planning, directionality, and visual motor skills

    A scooper bowl with suction base can be  help with scooping development and bilateral coordination at this stage.

    The child at this age can hold a spoon with a gross grasp or palmer grasp with an inverted wrist. They will dip the spoon in food. The spoon will make it back to the mouth, but typically, the spoon is only touched to the lips. They will not likely remove all of the food from the spoon using their lips at this point. The motion of the spoon is entirely with the shoulder and elbow. The wrist is in one position so that the spoon is dipped into the food upside down. You’ll see increased shoulder abduction in order to get the spoon into the food. The spoon may be upside down in their mouth too.

    Read more in a related blog post about how to hold a spoon.

    Feeding Skills at 15-18 Months

    The child is able to support the bowl with one hand while scooping with a spoon. Children can hold a small cup and pick out pieces of dry cereal or snacks.

    Fine motor skills are developing quickly.

    Drinking from a cup can move from a sippy cup to a spouted cup. Other young toddlers can drink from a straw. Holding the cup moves from a two handed grasp to a single grasp. You’ll see grasp on the handle of a sippy cup or spouted cup begins to move from a gross grasp to a pincer grasp. This grasp pattern development occurs in this later stage of toddler range because of the weight of the cup/drink.

    By the end of this age range, the 18 month child can hold an open cup on their own to pick up, drink, and set the cup back down with just some spilling of the liquid.

    Feeding Skills at 18-24 Months

    As a child gets closer to two years of age, the variety of foods increases and this allows for greater exposure to textures of foods (mushy, crunchy, etc.) and types of foods (liquids, solid foods, mixed consistency foods).

    The child will typically be able to drink from a cup with accuracy and with one hand but with more accuracy and precision. As the child moves toward two years, you can see a desire to drink from an open cup, but the accuracy of motor control and attention skills are not there for this type of cup.

    There will be more coordination of the spouted cup or sippy cup and accuracy, with less spillage.

    At this stage, the child will use a dominant hand in self-feeding and will begin to supinate the forearm when scooping with a spoon, resulting in greater accuracy. This looks like a typical spoon motion with the wrist, however there will still be a palmer or gross grasp on the spoon.

    By two years, the toddler can use the spoon to scoop and feed themselves chunkier or thicker foods such as applesauce, mashed potatoes, etc.

    Development of bilateral coordination for feeding skills is essential for accuracy and improving independence in self-feeding in kids.

    Feeding Skills at 24-36 Months

    During this stage, the child’s dominant hand is more established and the child can support with the non-dominant hand with greater accuracy.

    There will be greater control of forearm supination so that the palm is facing upward when scooping. Typically, the child is able to self-feed without assistance.

    Around 2.5 years, the child can drink from an open cup with one hand. A small, “pixie” cup or slightly larger small cup is great for this. They can also hold the spoon with a “palm up” position on the spoon. This allows for greater accuracy and ability to self feed thinner soups or cereals with milk.

    By the end of this stage, around 3 years, the child can use a fork to pierce soft foods and they can brink the fork to their mouth and remove the food using their teeth and lips.

    Feeding Skills at 3-4 Years

    The child will begin to use a fork with improving accuracy. They can use a straw and hold the cup with one or both hands. They can also hold a cup while drinking from a straw on their own, and without assistance.

    The child can use a pitcher to pour water into a cup, demonstrating bilateral coordination with advancement to the dominant hand/assisting hand stage.

    The child will use both hands together with improving coordination in self-feeding. At this age, it’s a great time to get kids involved in helping to cook recipes. This experience in the kitchen along with an adult supports development of fine motor, sensory motor, and visual motor skills. Check out these cooking with kids recipes to support these areas.

    Feeding Skills at 4-5 Years

    Children will be able to use a knife to spread butter or peanut butter with the dominant hand while holding the plate or bread with their non-dominant hand.

    Beginning use of child-friendly knives is appropriate. They will press with the knife rather than chopping or slicing.

    In this stage, you’ll see a coordinated use of hands, in most cases. At this age, it’s important to expose the preschool child to lots of fine motor play and sensory motor play experiences to support development and exposure to motor activities. These promote development needed for fine motor skills and success in later years in the classroom.

    Feeding Skills at 5-6 Years

    Children will use a fork and spoon accurately. They will be able to scoop, poke, and stab with a fork using appropriate positioning and without use of the non-dominant hand to support the plate.

    The child will begin to use a knife to cut foods.

    Feeding Skills 6+ Years

    The child will be able to cut meat with a knife with increasing accuracy and ability. As they develop, the child will increase coordination with knife and fork use in a coordinated manner.

    Spilling of cups and foods decreases with age and development.

    Attention in feeding tasks develops as children progress through the various stages, too. This makes a big difference in accuracy as well.

    Trouble with Feeding Development

    It’s important to remember that all children are different and the developmental milestones for feeding tasks listed above are not set in stone. There is always fluidity with development and feeding skills are no different.

    If there are skills that seem to be delayed, be sure to reach out to the child’s pediatrician and a pediatric occupational therapist for individualized feeding evaluation and assessment as well as a specific treatment plan based on the individual’s needs.

    Some things to consider that may be impacting feeding development include oral motor problems, determining if the feeding development issues are a result of sensory vs. oral motor considerations, or there is a need for specific adaptive feeding equipment.

    Development of bilateral coordination skills in feeding occurs throughout childhood.

    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 extremely 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.

    Adaptive Equipment For Eating

    Adaptive equipment for eating

    This article covers adaptive equipment for eating, including adaptive feeding equipment, assistive feeding devices, adaptive utensils, plates, bowls, and other tools to support functional feeding skills.

    One of the main paths that occupational therapists help people achieve success in their daily occupations is through adaptive equipment and technology. There are so many great feeding products and eating tools available to increase independence, and today we will start off the conversation by introducing adaptive equipment specifically for feeding. 

    Adaptive equipment for eating

    A great place to start with learning more about adaptive equipment for eating and the possible need for reaching out to occupational therapy for adaptive eating tools or support is this resource on Pediatric Feeding: Is it Sensory, Oral Motor, or Both?

    Adaptive Equipment for Eating

    When it comes to helping individuals become more independent with daily occupations, feeding and eating skills have a big role. Occupational therapy, being the holistic profession that it is, recognizes the overall piece of eating has on wellness and wellbeing, nutrition, and day to day functioning. OTs focus on both the feeding aspect for nutritional intake as well as functional eating skills in use of utensils, cups, and bowls for independence.

    Let’s take a look at various adaptive equipment tools for feeding and eating:

    Adaptive utensils for feeding needs

    Adaptive Utensils

    Adaptive dinnerware includes adjusting handles on eating utensils, adding width to the utensil handle, adding weight or length, and addressing the ability to hold a fork and spoon, or knife. Other adaptive feeding needs cover difficulty bringing food to the mouth or the ability to remove food from the utensil as a result of oral motor issues.

    Let’s take a look at various adaptive utensils.

    Amazon affiliate links are included below.

    EazyHold Silicone Silicone Aide-Basically a silicone universal cuff, this adaptive utensil tool is perfect for feeding! The silicone texture makes it easy to clean, and it comes in sizes for newborns through adults. This piece of equipment can be placed around the hand and hold common objects like forks, spoons, markers, and paintbrushes making it a one-stop device for turning household spoons, knives, and forks into adaptive eating utensils. It can remarkably increase independence for individuals that demonstrate deficits in grip strength. 

    Maroon Spoon– This adaptive feeding utensil is a classic! The maroon spoon has a shallow spoon depth that can assist in feeding for users with poor lip closure, oral hypersensitivity, or tongue thrust. 

    Weighted, Thick Handled Utensils– These weighted utensils have thick handles that are great for those who can grasp a wide handle but have a harder time holding on to something smaller that requires more grip strength. If this is the case, built-up handles are a lifesaver!

    You can also use Viva Foam Tubing to make any household spoon, fork, or knife handles thicker and easier to grasp. The added weight of these utensils is also great for individuals who have tremors – the extra weight helps to combat the motion of the tremor, leading to a more successful meal time. 

    Textured Spoons– The texture on the spoon provides oral-motor stimulation to the mouth, increasing wanted oral movement patterns and decreasing hypersensitivity. The texture can also cue the user to engage with the tastes and textures while feeding. This spoon comes with extra-long handles to make hand over hand assist a bit easier, too! 

    These bendable textured spoons are great for self-feeding and oral motor stimulation as they have a smaller, hand-held size and can offer different textures for gum and tongue sensory input.

    Off- Set Spoon– This tool, and many other utensils like it, allow for easier self-feeding for individuals who have limited mobility. The angle of the spoon is turned toward the person, instead of being straight, so that they can bring their spoonful of food directly to their mouth without having to change the orientation of the spoon or their bodies. 

    Adaptive plates and adapted bowls for feeding issues

    Adaptive Eating Plates and Bowls

    When it comes to a container to hold food, plates and bowls can look like many things. Here, you’ll find recommendations for lipped plates, suction cup

    Scooper Plate– A lipped plate is just one way to help individuals scoop food from the plate surface, and not onto the table. This scooper plate is a dinner plate with a lip, or a higher edge. Here is another must-have item for individuals that have trouble scooping or stabilizing their plate or bowl.

    This “scooper plate” is a plate with high walls like a bowl that have been specifically designed to make it easier to scoop and pick up food items with a utensil. Even better, there is a suction cup feature at the bottom to secure it to the tabletop for more stability while scooping. You can also get the scooper bowl here.

    Plate Guard– Similar to the scooper plate, these plate guards can be added to any of your existing plates to add a wall to scoop against. This reduces spills, food waste, and time spent chasing food around with a utensil. That being said, there is much to learn from messy food play.

    4-Square Meal Plate– Some feeding therapy involves increasing food repertoire for picky eating. This plate can be a great tool to help make mealtime fun and engaging for kids.

    Adaptive cups and adaptive spoons for feeding needs

    Adaptive Cups

    Adaptive cups can help with drinking without lifting the head or chin or can help address other motor control and strength challenges. For individuals that struggle to hold a cup or sip from the edge of a cup, there are straw options as well. Below, you’ll find adapted cups that are designed for those with dysphasia or aspiration precautions. Those requiring thickness needs or safety concerns with swallowing liquids should consult a professional. Read this resource on oral motor issues and feeding needs to get started.

    Flexi Nosey Cup– This is a flexible drinking cup that also has a space cut out of it to fit a person’s nose. This is a simple and effective way to improve the independence of those who are limited in their ability to tilt their head back while drinking. With the space cut out for the nose, there is no need to tilt their head back while using this cup. The flexibility of the cup can control the flow of the fluid as well, to promote safe swallowing. 

    Bear Straw Cup– This kit can help teach a child how to drink out of a straw. The design keeps the liquid near the top of the straw so that less effort is required to take a sip. This can be great for those with oral motor deficits or those just learning how to suck. The kit comes with a lip block to prevent biting on the straw or having the straw enter the throat, and encourages oral motor exercise as well! 

    Recessed Lid Cup– This drinking cup is designed with two handles and a recessed lid that can improve lip closure while avoiding sippy cup use. Why do we want to avoid sippy cups? Short answer: if they are used to exclusively, for too long, they can cause dental issues and speech problems. The recessed lid cup mimics drinking from an open cup without all the spillage. Plus, it improves lip closure and tongue retraction for improved oral motor function. This kind even comes with two lid options, one that is suitable for straw use, and the other for typical drinking. 

    Flow Control Cup– This cup helps with oral motor control, lip closure, and tongue mobility that impacts sucking from a straw and managing the flow of liquids when drinking from a cup.

    Extra-Long Drinking Straw– This flexible drinking straw is extra long, addressing mobility needs that limits an individual’s ability to move closer to a cup and straw that are positioned on the table surface.

    If you are a therapist or another professional looking for brands to support during feeding therapy, take a look at Ark’s products. They make tons of oral motor tools for desensitizing and strengthening a child’s mouth to encourage the development of food repertoire and safer, more independent feeding and swallowing. 

    Finally, if adaptive feeding equipment is something that needs to be further adapted to meet the specific needs of an individual, don’t forget the many uses that Dycem will have in addressing specific needs.

    Sydney Thorson, OTR/L, is a new occupational therapist working in school-based therapy. Her
    background is in Human Development and Family Studies, and she is passionate about
    providing individualized and meaningful treatment for each child and their family. Sydney is also
    a children’s author and illustrator and is always working on new and exciting projects.

    Messy Eating

    Benefits of Messy eating for babies and toddlers

    Have you ever noticed that small children eat meals with recklessness? Bits of food covers the face, cheeks, hands, lap, floor, belly, and even hair. Part of it is learning to use utensils and manage food on the fork or spoon. But there’s more to messy eating too! Messy eating for a baby or toddler is actually a good thing, and completely normal part of child development. And, letting a small child get messy when they eat, and even playing with their food as they eat is OK!

    Messy eating in babies and toddlers has benefits to developing tactile sensory challenges and fine motor skills in young children.

    Messy eating

    I’m sure that your mother never told you it was okay to play with your food at the dinner table, but I’m here to tell you otherwise. Playing with food is not only okay, it is vital to development of self feeding skills and positive engagement with food. When young children play with their food they are engaging in a rich, exploratory sensory experience that helps them develop knowledge of texture, taste, smell, changing visual presentation of foods and oral motor development.

    When play with food is discouraged it can lead to food texture issues, picky eating, oral motor delays and increased hesitancy with trying new foods later on.

    Eating with hands- Messy benefits

    When solid foods are introduced to baby, it is often a VERY messy ordeal. There is food on the chair, the bib, the floor, you…everywhere but the baby’s mouth. Often times, parents may feel discouraged or don’t like the mess that is the result, but it is OK. In fact, the messier the better.

    Exploring food textures with the hands provides tactile experience to the hands, palm, and individual fingers. Are foods sticky, chunky, goopy, or gooey? All of that exposure to the hands is filed away as exposure to textures.

    Picking up and manipulating foods offers fine motor benefits, too. Picking up and manipulating bits of food offers repetition in pincer grasp, graded precision, grasp and release, eye-hand coordination, bilateral coordination, crossing midline, and proprioceptive feedback. All of this is likely presented in a baby seat or high chair that offers support and stability through the trunk and core. When that support is offered to babies and toddlers, they can then work on the distal coordination and dexterity. At first, manipulation of food is very messy as those refined skills are developed, but it’s all “on-the-job training” with tasty benefits!

    Research shows that a child moves through a series of exploratory steps before successfully eating new foods. This process involves messy play from the hands, up the arms, onto the head and then into the mouth. The steps of this process cannot happen unless the child is encouraged to touch, examine and play with their food. In today’s culture of sterilization and cleanliness, this often counterintuitive to parents and a hard pattern to break.

    Promoting Play with Food

    Mealtimes can be rushed affairs, making it hard to play with food, but they are not the only times we engage with food throughout the day.

    Cooking and meal prep are two of the most common opportunities for play and engagement with food. These activities present perfect opportunities for parents to talk about color, size, shape, texture, smell and taste of the foods that are being prepared. Use of descriptive words,
    over exaggeration when talking about and tasting foods, along exploration opportunities develop a positive interest in foods.

    Babies can be involved in kitchen prep as they play with appropriate utensils and kitchen items like baby-safe bowls or pots. Toddlers enjoy being involved in the food preparations and can wash, prep, and even chop soft foods with toddler-safe kitchen tools.

    Explore these cooking with kids recipes to get small children involved in all the benefits of the kitchen.

    Here are more baby play ideas that promote development.

    Food Art

    Free play with foods like yogurt, jello and applesauce are also great opportunities to promote messy play and creativity. Utilize these foods for finger painting, or painting with other foods as the brushes. This activity challenges tactile and smell regulation, along with constant changes in
    the visual presentation of the food.

    Creativity with Food

    When presented with food for free play, or at the dinner table encourage their creativity–carrot sticks become cars or paint brushes, and raisins become ants on a log.

    The sillier the presentation, and more engaged the child becomes, the more likely they are to eat the foods you have presented to them. Especially, if these foods are new, or are non-preferred foods. High levels of over exaggeration also leads to increased positive experiences with foods, which in turn leads to happier eaters, and less stressful mealtimes
    down the road.

    Ideas like these flower snacks promote healthy eating and can prompt a child to explore new textures or tastes in a fun, themed creative food set-up.

    Messy Eating and Oral Motor Development

    Not only does play promote increased sensory regulation and positive engagement with foods, it also promotes oral motor skill development.
    Oral motor skill development is promoted when a variety of foods are presented and the mastered skills are challenged.

    Here is more information on oral motor problems and feeding issues that are often concerns for parents. The question of feeding concerns and picky eating being a sensory issue or oral motor motor concern comes up frequently.

    Foods that are long and stick like such as carrots, celery and bell peppers, promote integration of the gag reflex, along with development of the transverse tongue reflex that later supports tongue lateralization for bolus management.

    Foods such as peas, or grapes promote oral awareness and regulation for foods that “pop” when bitten, and abilities to manage multiple textures at one time.

    Messy Eating and Positive Mealtimes

    Whether you have a picky eater, or are just trying to make mealtimes fun, play is the way to go!

    Play with food is critical to development of oral motor skills and sensory regulation needed to support positive meal times. Through the use of creative play, exposure, and over exaggeration these milestones can be achieved.

    Although the goal is for your child to eat new foods there are many steps we need to conquer before getting there. Don’t worry, these can be fun and stress free! 

    Let me ask you a question. If you were presented with a new food, something so new and anxiety provoking that you don’t want it near you and you definitely don’t want to touch it; do you think you would want it anywhere near your mouth? About in your mouth? Even more, how about swallowing it? The answer for most would be NO WAY! 

    Well, we can’t expect the same from our kids. If they don’t want to look at or touch a food, they most definitely will not want to eat it! So before getting kids to put new foods near or in their mouth, we need to take several steps back and learn how to interact with it. This is where the fun can come in! 

    This week we are going to experiment with various ways of play or interacting with foods. Remember, the goal in not to eat it. The goal is simply to interact with it and hopefully to start getting messy with it! Let’s kid you child comfortable with touching food and have fun doing it. This will not only get them a few steps closer to eating it, but it will also build positive associations with the food and also make them more comfortable with various aspects of it. This can include the color, texture, shape, smell, etc. The more foods we play with, the more of these they are feeling comfortable with. So in short, let’s start our food journey with our hands and our eyes by getting messy! 

    Development of Oral Motor Skills

    Wondering about oral motor skills development or where to start with oral motor therapy? Below you will find information related to the development of oral motor skills. This oral motor development information can be used to guide oral motor exercises and oral motor skills for feeding.

     

     
    Use this guide on development of oral motor skills to address oral motor skill therapy and as a guideline to develop oral motor exercises in oral motor therapy.

     

    Development of Oral Motor Skills

    Oral motor skills are the finest of the fine motor skills we develop as human beings. It begins in the womb, and is fully developed and established by 3 years of age. Like many other skills we learn, oral motor development is supported by primitive reflexes, postural control and other physiological milestones developing in synchrony. When the synchrony is broken, problems arise.

    Oral Motor Skills: Where it all Begins

    Oral motor skills start in the womb with the development of primitive reflexes that support feeding at full term. It is important to note that these reflexes develop in the 3rd trimester between the 28th week and the 37th week gestation. When working with a pre-term baby, these reflexes have not developed and successful feeding will require higher levels of support from an outside source.

    Reflexes Established by Term:

    * Gag reflex
    * Rooting reflex
    * Transverse Tongue Reflex
    * Non-nutritive sucking
    * Nutritive sucking
    * Coordinated suck/swallow/breath
    * Swallow reflex
    * Phasic bite reflex
    * Palmomental reflex
    * Sucking patterns are non-volitional

    A full term infant is ready to breast or bottle feed with the above supports in place.

    Oral Motor Skills Birth to 3 Months of Age

    As reflexes begin to integrate, feeding becomes more and more voluntary, and less of a non-voluntary response to stimuli from the breast or bottle. This occurs in a full term infant around 6 weeks of age. This is important to note, as unsuccessful feeding in the first 6 weeks of life, can set the tone for developing eating patterns throughout life.

    Oral Motor Skills and Feeding at 3 – 7 Months of Age

    By 4 months of age, most infants have gained fair head control and are able to remain in an upright position with support, and parents are beginning to introduce puréed foods. As they have grown, the anatomical structure of their jaws and tongues have dropped forward to support munching patterns. They also may open their mouth when a spoon is presented and are able to manage thin purees with minimal difficulties.

    Oral Motor Pattern 3-7 Months

    * Munching patterns
    * Lateral jaw movement
    * Diagonal jaw movement
    * Lateral tongue movement

    The development of these patterns allow infants to be successful with thin and thick purees, meltables and soft foods such as banana and avocado.

    Oral Motor Skills and Feeding at 7-9 Months of Age

    Between 7 and 9 months of age, infants are now moving into unsupported sitting, quadroped and crawling. This development supports jaw stability, breath support and fine motor development for self feeding skills. Infants at this age now begin to be able to successfully manage “lumpy” purees, bite and munch meltables and softer foods with assistance and the development of rotary chewing begins.

    Oral Motor Patterns 7-9 Months of Age

    * Lip closure
    * Scraping food off spoon with upper lip
    * Emerging tongue lateralization
    * Movement of food from side to side

    The above skills are clearly noted during the 7-9 month age range. If these skills are missing, eating a larger variety of textures will become difficult.

    Rotary Chewing

    Rotary chewing is broken into stages. The first stage being diagonal rotary chewing, and the second being circular rotary chewing.

    Diagonal Rotary Chew

    Diagonal rotary chewing is when the jaw moves across the midline in a diagonal pattern and comes back. This type of chewing often looks like an X from a frontal view.

    Circular Rotary Chew

    As the child develops, a circular rotary pattern emerges. In this pattern, the child’s jaws line up, slide across, jaws line up, and slide across again, looking like a circle from a frontal view.

    Rotary Chewing Supports

    Rotary patterns begin emerging around 10 months of age. The child at this time is also developing dissociation of his head from his body. This supports increased independence with biting pieces of food, lateralization of a bolus across the midline, and decreased spillage from the lateral sides of the mouth.

    Oral Motor Skills at 12-15 Months of Age

    By 12 months of age, the child has developed the oral motor basics to support feeding. As time goes on, the child will practice these skills resulting in less messy eating and the ability to handle more challenging foods. At this age, a child is able to manage foods with juice, and chew and swallow firmer foods such as cheese, soft fruits, vegetables, pasta and some meats.

    Oral Motor Skills at 16-36 Months of Age

    Between 16 and 36 months of age, the child continues to develop their jaw strength, management of a bolus, chewing with a closed mouth, sweeping of small pieces of food into a bolus, and chewing ‘harder’ textured foods such as raw vegetables and meat. A full circular rotary chew should also be developed at this time to support eating all varieties of foods.

    Impact of Delayed Oral Motor Skills

    Oral motor skills play a large role in a child being a successful eater and having a positive experience with food. When a skill is missing, feeding becomes difficult and stressful for everyone involved. By assessing where the delay in skill is, new skills can be developed successfully, leading to an efficient eater.

    Read here about oral motor skills and the sensory components that play into picky eating and problematic feeding.

    Looking for more information on oral motor problems? You’ll love these oral motor skill resources: 

       

     

     
     
    Oral motor skill development in kids and how development of oral motor skills translates to feeding problems

     

    Pediatric Feeding: Is it Sensory, Oral Motor or Both?

    Below, you will find a blog post on pediatric feeding therapy and answers to initial questions about feeding therapy such as “Are pediatric feeding issues related to sensory needs, oral motor problems or both?” and thoughts about where to begin with pediatric feeding therapy techniques. A question of sensory or oral motor concerns should be taken into consideration when feeding developmental milestones aren’t being achieved on target.

    Occupational therapists and parents often wonder if feeding problems are related to sensory issues or oral motor skills. This article on pediatric therapy addresses that question.

    Pediatric Feeding: Is it Sensory, Oral Motor or Both?

    When I was in grad school, we had one, three hour lab on feeding, and were told, Speech would handle feeding, so don’t worry.  Little did I know that what I thought was going to happen, was very far from reality.

    Feeding Therapy Evaluation

    When a child enters a therapy clinic for an OT feeding evaluation, we are prepared for sensory deficits to be present. What we are not prepared for in school, is the potential, and probable oral motor component. This is a skill that most of us learn on the job, in trial by fire, with limited guidance. Or, so was my experience.

    Due to the high level of overlap between Speech and OT when it comes to feeding, this often is a problem that OT’s face. Depending on the setting, and even the facility you are in, can determine whose job it is to handle feeding clients.

    A majority of professionals maintain that if it appears sensory based and the child has a limited diet, eats only certain textures or colors, it is for OT. If it appears oral motor in nature and the child cannot chew or manage a bolus well, it is for Speech to handle.

    Herein lies the problem and common misconception about problematic feeders. Feeding challenges are more than just sensory, or just oral motor.

    It is both sensory and oral motor based. This can lead to a very challenging, and complex situation for an OT who is new to feeding.

    Oral Motor Skills and Sensory Challenges in Feeding Therapy

    When a child limits the textures and variety of foods they eat, they limit the growth and development of their oral motor skills.

    Let’s take a child who eats only pureed foods, and refuses solids of any kind for an example.

    Oral motor skills needed to eat a thin puree off a spoon and to eat a carrot stick are vastly different.

    Puréed foods require minimal bolus management of a thin food that quickly runs down the esophagus with minimal effort. The puree is also smooth, eliminating any scary “texture” for the child to manage.

    The carrot stick, on the other hand requires the child to have awareness of his mouth, tongue, and bite pressure before even creating a bolus with the bite of carrot. The child also has to manage the bolus and break down of carrot efficiently while chewing and then swallowing.

    Add in the sensory component of crunchy, wet and constantly changing size of the pieces of the carrot, and the child can become easily overwhelmed.

    And so, the vicious cycle of a limited diet begins. Lack of confidence with oral motor skills and sensory deficits can lead to problematic feeders.

    Feeding Therapy Goals

    The above example is a frequent experience that many OT’s have faced when completing a therapy feeding session. With lack of exposure and continued refusal to attempt new foods, the child’s oral motor skills are never able to develop to support the trial of new foods continuing the cycle.

    As occupational therapists, it is our job to help these children become functional eaters through the use of sensory desensitization and remediation of delayed oral motor skills.

    Oral Motor Development in Feeding Therapy

    As oral motor development is a lengthy topic, the next post will address oral motor development and food pairings to determine gaps in skills and provide effective remediation of delayed skills.

    Check out the handout below to show parents and help explain the overlap of sensory processing and oral motor skills in problematic feeders.

    Would you like to print this visual guide? Click here to access the printable pdf in our free resources library. You will also receive weekly newsletters full of therapy resources, tips, strategies, and information. The OT Toolbox newsletter is perfect for therapists and those working with occupational therapists.

    Disclaimer: Feeding difficulties stem from a variety of difficulties including medical, structural, sensory deficits and skill deficits. The main discussion of this post is to examine the crossover of sensory and oral motor skills. Medical and structural concerns will be addressed in future posts.

    A little about Kaylee: 
    Hi Everyone! I am originally from Upstate N.Y., but now live in
    Texas, and am the Lead OTR in a pediatric clinic. I have a bachelors in Health Science from Syracuse University at
    Utica College, and a Masters in Occupational Therapy from Utica College. I have been working with children with special needs for 8 years,
    and practicing occupational therapy for 4 years. I practice primarily in a
    private clinic, but have experience with Medicaid and home health settings
    also. Feeding is a skill that I learned by default in my current
    position and have come to love and be knowledgeable in. Visual development and
    motor integration is another area of practice that I frequently address and see
    with my current population. Looking forward to sharing my knowledge with you all! ~Kaylee Goodrich, OTR

    Click on the images below to check out these related articles: 

    Jaw instability is an oral motor problem that results in impaired eating and drinking skills.  Exaggerated jaw movements are an oral motor problem that interfere with feeding including eating and drinking. Here are reasons why this oral motor issue happen and how it relates to feeding in kids. Jaw clenching is an oral motor problem that interferes with feeding and eating. Help to understand jaw clenching and reasons it might occur. Jaw thrust is a common oral motor problem that interferes with feeding. Here are the underlying causes and how jaw thrust impacts feeding in kids.