Question & Answer - Feeding, Eating, & Drinking
I am working with a 3-year-old boy who is dependent on purees. He puts "meltables" in his mouth and mashes them with his tongue but does not chew. What steps would you take to help him learn to chew foods?Anonymous Submission
Answer from Diane Bahr, MS, CCC-SLP, Feeding Specialist
Thank you for asking this question. This is a common problem in young children who have not progressed through the critical stages of feeding development in the first two years of life. This boy needs to develop oral awareness and tolerance for food management as well as appropriate tongue movement and chewing skills. Here is how I might approach treatment.
Oral Awareness and Tolerance for Food Management
Teach his parents oral massage as part of his tooth brushing routine (3 times per day) to ensure that he has typical oral awareness and tolerance for sensory input throughout his mouth (Bahr, 2010, pp. 125-136). Foods have many sensory properties like taste, texture, temperature, etc. Therefore, it is important that he be comfortable with oral sensory input.
Tongue Movement and Chewing for Food Management
I would teach his parents to systematically work on tongue movement and chewing simultaneously (as he has the tolerance and awareness needed for this type of treatment). Ideally, his parents will want to do these activities with foods (if he is ready for foods). If he is not ready for foods, his parents can work with mouth items such as Chewy Tubes, ARK Grabbers, etc. to teach similar skills, incorporating foods as soon as possible.
Working with Food to Teach Tongue Lateralization and Chewing
Many children mash foods with their tongues and don’t chew because they don’t have adequate tongue movement to place and collect the food within the mouth for chewing. Tongue lateralization (i.e., tongue tip moving from the front teeth to the back teeth and throughout the cheek areas) can be taught with foods or with other mouth items if the child is not ready for foods. Chewing on foods is slightly different than chewing on toys or other items, so you ultimately want his parents to use real foods when possible. Here are some ideas for working with foods.
Since he currently eats purees, he may like these activities to encourage lateral tongue movement:
• Cut a straw in half. Inject it with a pureed food that he eats and will taste good frozen (e.g., pudding, yogurt, and pureed fruit). Clip off both ends of the straw with binder clips. Freeze it. Cut off one end of the straw. Have him bite-bite-bite on the end of the straw from his front teeth to his back molars. As he bites on the straw, the food will come out. He will have the opportunity to use his tongue in an increasingly mature manner as his tongue follows the food (Overland & Merkel-Walsh, 2013).
• Fill a syringe with a pureed food that he likes. Then inject a small amount of food at a time, beginning behind the front teeth and progressively moving to each back molar area. Watch his tongue follow each food placement as you change the position of the syringe. He may bite down (lightly) on the syringe as you do this. Once he has the tongue movement, you can inject small amounts of food at each back molar area to encourage his tongue to pull back for the swallow (Overland & Merkel-Walsh, 2013).
When he is ready to work with other food textures:
• Place foods in cheesecloth or a safe feeder. Be sure the foods are biting and chewing size (i.e., not too big or wide). Have him bite-bite-bite on these from the front teeth to the back molars (with the tongue following). Do this on each side of the mouth. When the food reaches the back molars, have him chew the foods 12 to 15 times at each back molar area (or until the food breaks down). I usually recommend working toward 12-15 even, solid chews alternating sides for 3 sets. This activity will help him learn to chew foods well for good digestion. Digestion begins in the mouth as saliva is mixed with food (Bahr, 2010, pp. 176-181).
• Next, teach his parents to present foods (cut into strips) to his back molars for chewing (first in a safe feeder, then without the safe feeder as he is ready). These foods may include Veggie Sticks ("meltable"), vegetable sticks (slightly cooked if needed), fruit leather, dried fruit, etc.
• Appropriately sized, cubed foods (i.e., foods that fit easily between his molars) can then be placed at his back molars for chewing using a cocktail fork (Overland & Merkel-Walsh, 2013).
Working with Non-Food Items to Teach Tongue Lateralization and Chewing
• If he is not ready to work with foods, tongue lateralization may be taught by dipping the Chewy Tube or ARK Grabber into a preferred taste (e.g., yogurt or pudding). Then have him bite-bite-bite on the mouth item from the front teeth around to the back molars with the tongue following. Once the chewing item reaches his back molars, do the jaw work (i.e., 12-15 chews, alternating sides for 3 sets).
• Teach his parents to do a systematic chewing activity with him every night before bed using Chewy Tubes, ARK’s Grabbers, or something similar. Parent and child will work toward 12-15 even, solid chews at each back molar area alternating sides for 3 sets (making sure his jaw is comfortably aligned). It is best if a parent does the activity along with the child as a role model. They can look at books while doing this activity, as chewing can also encourage attention, focus, and concentration (Bahr, 2010, pp. 136-147).
More specific, systematic oral sensory-motor treatment information for teaching skills such as chewing can be found in books by Bahr (2010), Morris and Klein (2000), as well as Overland and Merkel-Walsh (2013). Specific, systematic jaw work can be found in programs by Lowsky (2011), Rosenfeld-Johnson (2007) and Schiavoni (2000).
• Bahr, D. (2010). Nobody ever told me (or my mother) that! Everything from bottles and breathing to healthy speech development. Arlington, TX: Sensory World.
• Morris, S. E., & Klein, M. D. (2000). Pre-feeding skills. A comprehensive resource for mealtime development (2nd ed.). San Antonio, TX: Pearson.
• Overland, L., & Merkel-Walsh, R. (2013). A sensory motor approach to feeding. Charleston, SC: TalkTools.
• Rosenfeld-Johnson, S. (2007). Assessment and treatment of the jaw: Putting it all together: Sensory, feeding, speech. Charleston, SC: TalkTools.