While developing in utero, children begin to explore with their mouths and practice feeding skills. As children learn and grow, their feeding skills should evolve and mature. While feeding/eating may seem like a simple process, it is actually a very complex skill.
If your child is having feeding difficulties, you are not alone. Feeding concerns are becoming increasingly prevalent amongst parents of young children.
“The prevalence of feeding difficulties is approximately 25%-35% in children with normal intellectual and adaptive development. For those with developmental disabilities, the prevalence increases to 40%-80%. In particular, the prevalence of feeding difficulties is almost 90% in children with autistic spectrum disorders” (Yang, 2017, p. 381).
Causes of Feeding Difficulties
Many factors may contribute to feeding difficulties; however, the reason typically falls within one or more of these categories:
Medical
A variety of medical conditions can affect appetite, delay or interfere with oral-motor development, and cause negative food associations. Gastrointestinal conditions, such as chronic reflux and constipation, and complications from food allergies, such as eczema, cause discomfort and may lead to food avoidance. Sometimes, children are unable to protect their airway when swallowing food; this is called aspiration. Frequent aspiration can lead to pneumonia and chronic infections. Other medical complications include side effects from medication, history of tube feedings, and any medical diagnoses that affect cognitive and physical development.
Environmental
Children perform best when they have routines and schedules, which includes a mealtime schedule. Children learn that it is time to eat when they (mostly) are offered food at the same place and around the same time of day. This helps them develop hunger cues and encourages them to focus their attention on eating. Environmental distractions may make feeding more challenging. Mealtime should always be a positive experience. If mealtime becomes stressful, children will try to avoid the situation and may develop feelings of anxiety and fear. The goal is to help them feel safe and happy during mealtimes, so that they develop a positive relationship with food.
Oral-motor
As babies grow and develop, the muscles of their lips, cheeks, tongue, and jaw should become stronger and movements of these structures should coordinate to allow the child to progress from sucking to chewing. Children with delayed oral-motor skills are at a higher risk for choking. They may avoid certain foods and show a preference for softer textures because they are afraid of choking. Here is a general outline of oral-motor progression:
(please note that babies born prematurely or who have varying developmental abilities may be on a different timeline)
0-3 months
Babies use a wide range of reflexes and a suck/swallow/breath pattern when
drinking milk.They should enjoy exploring various textures with their hands and mouth.
4-6 months
Babies are able to manage smooth purees and will open their mouth in
response to a spoon. They may have some tongue protrusion with spoon feeding.
7-9 months
The gag response is less prevalent, and babies can manage lumpy purees and
ground food textures. They can bite and munch on softer foods and move food with an
up/down motion along with some diagonal jaw movements. They can close their lips to
remove food from a spoon and they begin to move food from side to side using their
tongue. Finger feeding begins.
10-12 months
Babies should have decreased spillage of food from their mouths when
chewing. They begin to use circular chewing patterns, and they can manage firmer
foods such as cheese, some meats, and pasta. They are able to manage food with
liquids and begin to drink from an open cup.
12-18 months
Chews food with circular jaw movements. They keep their lips closed when chewing
and have no food loss. Should be able to use a spoon with assistance. When drinking
from a cup, their jaw is stable. Should start weaning from the bottle.
18-24 months
Eats from a spoon without assistance and drinks from a cup with no liquid loss.
Tolerates most textures and can manage most table foods but may have difficulty with
raw vegetables and foods with tough skin.
***The majority of their daily caloric intake comes from solids rather than liquids.
24-30 months
Muscles of the jaw, cheeks, tongue and lip become even stronger and more
coordinated. When chewing, transfers food from both sides of the mouth. Accepts a
wide variety of textures. Proficient with a spoon but may need assistance with a fork.
Structural or neuromuscular abnormalities, such as a cleft palate, and low muscle tone can interfere with oral-motor development. Oral-motor dysfunction is strongly correlated with poor growth and adverse health outcomes. Sometimes oral-motor delay can be hard to notice; however, a licensed professional can determine if your child has any delays in this area.
Physical
In order for babies and children to successfully progress their feeding skills, they must also progress their physical development. Physical development allows children to develop the posture, strength, and coordination for successful feeding. Some important physical milestones include bringing hands to mouth, head control, sitting unsupported, progressive hand-eye coordination, fine motor control, and functional grasp patterns.
Sensory
Feeding and eating involves the use of many senses. Babies and children will observe how food looks, smells, feels (on their hands and in their mouths), and they will likely prefer certain tastes. Sensory issues strongly correlate to selective eating, which may lead to food refusal and nutritional deficiencies. Sometimes, children crave movement and have trouble staying seated during mealtime. Sensitivity to environmental stimuli, such as noise and lights, can also interfere with mealtime success.
Behavioral
As mentioned earlier, underlying medical conditions, sensorimotor concerns and environmental factors can contribute to negative behavioral changes such a fear, anxiety, food refusal, spitting and crying. Sometimes behaviors become learned and can persist even after the medical, sensory, or developmental problem has been addressed. Caregiver stress and responsiveness can also affect a child’s behavior.
Ways to Help
The first step in helping your child overcome feeding difficulties is to learn why they are experiencing difficulties, then learn how to help them become successful.
General tips for feeding:
- Make it fun! Force-feeding and negative feeding associations can actually worsen the situation.
- It’s okay to get messy! Children learn through their senses (touch, smell, taste, sound, and vision). Sometimes exploration is messy, but it is critical to learning.
- Be consistent when offering new foods! Sometimes children need to be exposed to a new food up to 20 times before they will taste/accept it.
- Have a routine! Offering food at a designated eating spot (e.g. highchair or table) and around the same times each day will help your child develop hunger cues and recognize that they are about to eat.
- Limit distractions! Children are always learning, and they are interested in what is happening around them. They may not focus on eating if they are distracted.
Red flags:
- Progressing food textures/consistencies at a much slower rate compared to same-aged peers
- Overstuffing
- Holding food in his/her mouth for several minutes before swallowing
- Food refusal
- Only eats a few types of foods (less than 10) or diet consist of very limited food groups
- Frequent gagging or choking
- Not gaining weight
(If your child is frequently choking or not gaining weight, please notify your child’s pediatrician)
While there are some wonderful pediatricians who recognize various feeding red flags, some will not recommend additional support unless a child is showing an obvious medical problem or weight loss.
If you have an intuition that your child’s feeding skills are not progressing as they should, schedule a free screening. We will discuss your concerns and develop a plan to help your child succeed. Early intervention is important!
