EARLY FEEDING SKILLS/ORAL MOTOR DEVELOPMENT & ASSESSMENT

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SOURCE: ASHA.ORG

Below is an overview of typical feeding development. Remember to consider your child’s motor skill development in relation to feeding skills and not just their chronological age.

Term babies: reflexes (rooting, gag, etc.)

0-3 Months (Newborn) Feeding Skills

• Latches onto nipple or bottle
• Tongue moves forward and back to suck
• Lips seal on breast nipple or artificial nipple, and function as a unit with tongue, cheeks and palate
• Tongue cups nipple to create intraoral negative pressure for sucking
• Sucks and swallows well
• Liquids only (milk/formula); cannot digest other types of food
• Oral reflexes begin to develop
• Phasic Bite (gentle pressure on gums where future molar development will erupt, causes newborn to bite reflexively)
• Feeding become more of a voluntary process
• Hand on bottle during feeding (2-4 months)
• Emission of crying sounds, vowel sounds, smiling and making gestures when talked to in "singsong" voice

Month Motor Development:

• Very little neck and head control
• Flexion
• Use facial expressions to indicate likes/dislikes
• Use both their hands and mouths to explore objects
• They will bring their hand to their mouth and will start to grasp objects and bring them to their mouth

What You Can Do:

• Babies need to be supported while being fed
• Play with your baby through opening your mouth and waiting for them to imitate
• Offer baby toys for them to practice grasping and exploring with their hands and mouth (be mindful of choking hazards – no small parts!)

4-6 Months (Supported Sitter) Feeding Skills

• Shows interest in food & opens mouth when spoon approaches
• Begins to eat cereals and pureed food. Smooth, pureed food (single ingredient only)
• Moves pureed food from front of mouth to back
• Taste preferences rapidly learned
• Feeding in a more upright position
• Lateral tongue movement (horizontal movement of the tongue)
• Spoon feeding with thin, smooth purees
• Both hands are introduced to hold the bottle
• Finger feeding is introduced
• Munch chew patterns are developing (Vertical munching of easily dissolvable solids)

Motor Development:

• May keep one or both hands on the ground while sitting
• Stronger core and more control over their neck and head movement, which is important for introducing solids
• Baby may begin to roll
• Turns head towards or away from food
• Reaches towards food when hungry

What You Can Do:

• Introduce a wide variety of tastes but do not force-feed – caution – introduce a new food every 3-4 days to help identify any possible allergies
• Present foods and wait for your child’s cues (ie. open mouth, turning head)
• Respect child’s refusal cues as well to help with development of their regulation
• Keep mealtimes fun; your child may refuse food in response to stressful mealtime interactions

7-9 Months (Crawler/Independent Sitter) Feeding Skills

• In a highchair, holds and drinks from a bottle
• Begins to eat thicker pureed and mashed table foods.
• After the introduction of lumpy solids, infants can co-ordinate all of their mouth movements; sucking, biting, and up and down munching (Early chewing can develop before the teeth have erupted as the gums are hard from the teeth within them)
• Remains full longer after eating
• Strong reaction to new smells and tastes
• Active lip movements
• Protrusion and retraction of tongue, possibly even during imitation
• Cup drinking can be introduced slowly
• Eating lumpy & mashed foods
• Increased jaw stability allows for chewing easily dissolvable solids
• Diagonal chew may begin to emerge, but full circular rotary chew not yet present

Motor Development:

• Sits up without touching their hands to the ground
• Starts to look and reach for objects, such as, food that is nearby

What You Can Do:

• Ensure your child is well supported in their highchair, and place bottle in midline in front of them so they can practice picking it up to feed themselves.
• Offer chew toys that can massage sore and swollen gums during teething
• Allow your child to explore foods with their hands (it’s ok to get messy!) and to self-feed
• Offer child-size spoons for your child to explore and play with
• When first introducing thicker purees, mix with a thinner puree

10-12 Months (Beginner Walker) Feeding Skills

• Finger feeds self
• Introduce soft solids
• Begins to hold spoon
• Lips may begin to strip food from a spoon
• Improved volitional lip closure
• Tongue begins to lateralize
• Eats an increasing variety of food
• Begins to use an open cup and can drink from a straw
• Ready to try soft-cooked vegetables, soft fruits, and finger foods
• Might be ready to start self-feeding with utensils
• Enjoys a greater variety of smells and tastes

Motor Development:

• May begin to pull up and stand unsupportive
• May begin learning how to use utensils during mealtimes
• Can start using an open cup
• Spills are expected and it will take practice

What You Can Do:

• Your child may be distracted by toys during mealtime. Keep mealtime fun by engaging with your child as they feed
• Continue to respect your child’s satiety cues (turning away, pushing or throwing food)
• Model using utensils and give your child time to try self-feeding on their own, use child-sized utensils with short thick handles – it takes practice!

12 Months and Up (Independent Walker) Feeding Skills

• Increases variety of coarsely chopped table foods
• Holds and drinks from a cup
• Improved biting skills
• Uses tongue well to move food from side to side in the mouth
• Imitates adult eating
• Child has developed basic the oral motor skills needed for feeding
• Open Cup drinking can be normalized
• Self-feeding is initiated (grasping spoon) with firmer foods (cheese, fruits, etc.)
• Drinking with 4-5 consecutive swallows
• Swallowing with lip closure
• Drink from straw with support
• Early up and down munch chewing of a broad range of foods persist
• Development of rotary chewing begins to emerge (jaw moves in a circular motion to grind food)
• Jaw/lip/tongue dissociation begins 
• Up and down tongue movements persist

Motor Development:

• Fully walking and exploring everything, including food!
• Should be able to eat more of the same foods as adults and more easily use utensils.

What You Can Do:

• Continue to structure mealtimes and enjoy eating with your child – as they will imitate your eating behaviors.
• You decide what your child eats; but they decide HOW MUCH.
• Work on feeding skills during play time and bath time (ie. using spoons & cups to practice scooping & pouring water)

By 24 Months (~2 Years) Feeding Skills

• Swallows well from a cup
• Fully drinks from straw independently
• Feeds self with fork and spoon
• Swallows food well with no loss of food
• Chews with jaw movements in all directions (round and round, up/down and side to side “Circular Rotary Chewing”)
• Munch chew pattern eliminated
• Able to chew hard solids 
• Grading jaw to bite – taking appropriate sized bites
• Able to chew with lips closed, without food falling from mouth
• Uses tongue to clean food from lips
• Uses tongue to sweep food from inner lip/cheek pockets and clean teeth
• Tolerates a wide range of textures, temperatures and foods
• Continues to show full dissociation of tongue/lips/jaws – tongue and lips moving independently from jaw
• Knows the difference between food and non-food items
• Scoops foods with a spoon, with some spills
• Starts to stab food with a fork and bring it to her mouth
• Shows clear likes and dislikes of some foods
• Nasal breathing day and night; and while chewing

Motor Developments

• Running

Between the ages of 2 and 3 years of age Feeding Skills

• Eats the same foods as the rest of the family
• Feeds well with utensils
• Has definite food likes and dislikes & refuse certain foods
• Possibly start to become a “picky eater” (see post next week!)
• Wipes own mouth and hands with a napkin or cloth
• Starts to serve themselves at the table with some spills
• Pours liquids into cup from a small container
• Tongue tip elevation with swallow

Motor Development:

• Jumping

****Foods such as grapes and hot dogs must still be cut in smaller pieces to avoid choking. It is important to continue to make meal times a fun and enjoyable experience for your family. Children will continue to practice and “fine-tune” their feeding and motor skills. 

If you have any concerns with your child’s development of the above feeding milestones, please contact a Speech Language Pathologist (SLP) for a full evaluation. 

Red Flags for Feeding Difficulties or some "red flags" that oral motor skills needs some attention:

If your child is exhibiting any of the following signs, it is important to reach out to a skilled and experienced Speech Language Pathologist (SLP)

• Arching body during feeding
• Coughing or choking during feeding
• Eyes watering during feeding
• Being very irritable/fussy during or after feeding
• Taking a really long time to feed (more than 30-45 minutes)
• Frequent spitting up/reflux 
• Frequent chest infections or pneumonia 
• Gurgly, hoarse, or breathy voice after eating
• Less than desired weight gain or growth
• Difficulty sticking tongue out
• Leaking food or liquid from the mouth
• Coughing, gagging, or vomiting during or after meals
• Overstuffing mouth with food
• Difficulty chewing
• Never chewed on toys or teethers as a baby
• Mashes food with tongue instead of chewing with molars
• Sucks on food instead of chewing
• Pocketing food in mouth
• Will hold food in mouth, sometimes for hours (often referred to as "pocketing food", there are other reasons children do this, as well)
• Gagging on food after it’s been in mouth (not immediately or at the sight of food, which might signal an oral aversion)
• Refusing new textures or temperatures of food
• Avoidance behaviors to specific foods and textures (gagging, vomiting, blocking the spoon with hands or closed lips, crying, pushing food away, etc)
• Abnormal bowel movements that last longer than a few days (diarrhea, constipation, loose stool)
• Skin reactions to foods (dry patches, hives, rashes) Note: If your child seems to be having a severe allergic reaction to a food (difficulty breathing, turning red, developing hives or rash on the face/chest), you should seek medical help immediately.
• Drooling (only consider when combined with other factors on this list, as drooling has many different potential causes. 

Do you feel that your child is not meeting all of their Feeding or Oral Motor milestones? Does your baby have difficulty feeding from a breast or bottle? Early Intervention is so important to identify or rule out any structural or functional barriers to feeding or speech. 

Early identification and intervention of Oral Motor and Early Feeding skills is critical. If you are concerned about your child’s oral motor/feeding development, speak with your pediatrician. In many cases, your doctor will refer you to a specialist known as a Speech-Language Pathologist (SLP), or Speech Therapist to address oral motor/feeding concerns. 

An Oral Motor/Feeding Assessment can determine if your baby's Oral Motor or Feeding skills are where they should be and can rule out structural Oral Restrictions (Tongue Ties) to determine if additional referrals or oral motor therapy is warranted.

Early Feeding/Oral Motor Assessment

(Breast/Bottlefeeding, Early Solids, Oral Restrictions/Tongue Tie, Oral Motor/Sensory Dysfunction)

What is the importance of Early Oral Motor/Feeding Skills?

This assessment is used by Speech Language Pathologists (SLP) to evaluate oral motor development, non-nutritive pre-feeding skills, and nutritive feeding skills. Oral motor development refers to the use and function of the lips, tongue, jaw, teeth, and the hard and soft palates. The range of movement, strength and coordination of these structures is is essential in speech production, safe sucking/swallowing, and consuming a variety of textures and for feeding tasks such as tongue lateralization, sucking, munching, licking, and swallowing. Oral motor skills also play a big role in the development of facial expressions, facial symmetry, sleep patterns and orthodontry.

The Development of Oral Motor Skills

Oral motor skills begin to develop in the womb and are fully functional by 3 years of age. Difficulties in the development of oral functions can lead to:

• Inability to latch onto a breast or bottle
• Excessive drooling
• Milk Leakage
• Difficulty with speech articulation
• Open-Mouth posture
• Snoring/apnea
• Inconsistent eating habits
• Decreased range of motion in the tongue
• Difficulty sucking, swallowing, and chewing

A comprehensive oral motor examination includes examination of:

• Breathing/Respiration Patterns
• Oral Habits (thumb, pacifier)
• Craniofacial/orofacial appearance (ie; symmetry,posture, growth patterns) and function of related muscles
• Hard and soft tissues of the mouth
• Tongue function, appearance, and rest position
• Chewing, drinking, and the oral phase swallow
• Identification of Oral Restrictions (lip or tongue tie)
• Infant feeding at breast or bottle
• Structure and function of lips, tongue and cheeks 
• Mobility of lips, tongue and cheeks

Following assessment, you will receive:

• A review of assessment findings
• Referrals to additional necessary providers 
• Possible presentation of an appropriate treatment plan such as our TINY MYO Program which focuses on Early Intervention of Oral Motor, Speech, Feeding and Myofunctional Skills in children ages 1-5+

If you are concerned about your child’s feeding development, contact your Pediatrician and/or schedule an assessment with a Speech Language Pathologist/Feeding Specialist.

CHECK OUT OUR TINY MYO PROGRAM - which focuses on Early Intervention for Speech, Feeding and Myofunctional Therapy for children ages 1-5+

Dena Freedman-Muchnick, M.S., CCC-SLP, CLC

Speech Language Pathologist

Certified Lactation Consultant

Orofacial Myofunctional Therapist

www.lactationspot.com

www.myofunctionalspot.com

www.speechlanguagespot.com

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