Question & Answer - Feeding, Eating, & Drinking
What do parents need to know when feeding their children from 12 to 24-months of age? Plus: Sippy Cups, Bottles, and Straws - Oh My!
Interview with Diane Bahr (DB) by Dr. Teresa Signorelli (TS) of Kids A to Z with Dr. T (November, 2014)
The following is a summary of a radio interview with Diane Bahr by Dr. Teresa Signorelli of Kids A to Z with Dr. T. You may listen to the actual interview by clicking on the “radio interview” link in the previous sentence. This interview is a continuation of a discussion begun in October of 2014 about feeding development.
In the interview, we discuss a little more information from the book Nobody Ever Told Me (or My Mother) That! Everything from Bottles and Breathing to Healthy Speech Development. This book was written as a resource for both parents and professionals (e.g., speech-language pathologists, occupational therapists, orofacial myofunctional therapists, lactation consultants, pediatricians, dentists, nurses, early interventionists, and others). It contains many detailed checklists and practical techniques that parents and others can use to keep kids “on track” in feeding, speech, and mouth development. The pages listed in this interview refer to pages in Diane Bahr’s book.
TS: Would you tell us who you are and what you do?
DB: I’m a speech-language pathologist, specifically trained in feeding therapy, with 35 years of experience. I’ve authored two books Oral Motor Assessment and Treatment: Ages and Stages and Nobody Ever Told Me (or My Mother) That! Everything from Bottles and Breathing to Healthy Speech Development. I’ve taught undergraduate, graduate, continuing education, and parent education courses. I’m also the co-owner of Ages and Stages®, LLC (Resources for Feeding, Speech, and Mouth Function) where our mission is to provide the best possible feeding, speech, and mouth development information for families and professionals. Our goal is to prevent feeding, speech, and mouth development problems when possible by helping parents keep their children “on track” developmentally.
TS: What is the most common question parents ask when they come to see you about a feeding concern?
DB: Parents often ask, “Why didn’t my pediatrician tell me or warn me about this problem?”
TS: What are parents often surprised to learn?
DB: Parents are often surprised to learn that we as feeding therapists have access to developmental information that they and their pediatricians frequently don’t have. This is one of the main reasons I wrote my parent-professional book and created our website.
TS: During our last conversation about feeding in October, we discussed feeding development from birth to 12-months. Can you tell us about the 12 to 24-month period?
DB: The 12 to 24-month period is a time for the refinement of feeding skills begun in the first year of life. The details I’m summarizing here can be found in checklists in my book Nobody Ever Told Me (or My Mother) That! Everything from Bottles and Breathing to Healthy Speech Development (pp. 184-185, 207-214). I created the checklists along with detailed descriptions of the information found in the checklists, so parents and pediatricians would also have the information that feeding therapists have.
During the 12 to 15-month period, a child can
-Pick up small pieces of food with the thumb and index finger
-Begin to self-feed with a spoon, but may turn the spoon over on the way to the mouth
-Begin to use a mature swallowing pattern where the tongue tip initiates the swallow on the gum ridge behind the top front teeth and lips close during the swallow
-Use the lips and cheeks to control food within the mouth
-“Bite through a soft cookie with the front teeth”
-Drink with consecutive swallows from an open cup with some spillage, a recessed lid cup with little spillage, and a straw cup with no spillage
During the 15 to 18-month period, a child
-Can scoop food with a spoon
-May still bite on an open cup rim for stability during drinking
-Can chew and manage food in an increasingly mature manner
During the 12 to 18-month period, a parent can serve chopped table food including soft meats to include fish without the bones. Parents should continue to avoid giving the child round foods such as hotdog pieces and whole grapes. This is the time when milk is frequently introduced. Bottle weaning began around 6 months with the introduction of open cup and straw-drinking experiences and is usually complete between 12 and 15 months.
During the 18 to 21-month period
-The child has good control of swallowing and can manage hard cookies
-Parents can serve “chopped table food to include many meats and raw vegetables”
By 24 months, a child should have most of the skills that you and I have. The child can
-“Bite through a hard cookie with ease”
-“Chew with lips closed”
-Use mature chewing
-Manage most foods cut into bite-sized pieces by the parent or created by taking bites
-Drink from an open cup using one hand without spillage
SIPPY CUPS, BOTTLES, AND STRAWS - OH MY!
TS: Would you talk to us about the development of drinking skills?
DB: Certainly. As we said in our previous interview and in our discussion of 12 to 24-month feeding, learning to drink from bottles, open cups, other cups, and straws is part of the developmental feeding process. Most parents of typically developing children do not know the specifics of this process because the information isn’t available to them. So, I would love to share the information that feeding therapists know about the development of drinking skills.
TS: What is best practice regarding bottle use? What are the pit falls or misuses you see?
DB: In Chapter 2 of my book, I give parents detailed information about bottle and breast feeding. I begin by having parents observe their babies’ mouth movements. Then, I instruct them in the best practices I know for breast and/or bottle feeding.
The best positioning for bottle feeding is to hold the baby’s body (even a newborn) at a 45 to 90-degree angle. We don’t want to lie babies down to feed them because the Eustachian tubes go from the back of the nasal/throat area and run horizontally to the middle ear spaces behind the ear drums. Babies who are fed lying down are at increased risk for middle ear problems (including ear infections) because there is an increased chance that fluid can run into the Eustachian tubes when a baby is fed lying down.
In terms of bottle-feeding methods, I recommend a method called “paced bottle-feeding” if the parents choose to bottle-feed. In paced bottle-feeding, you use a slow-flow bottle nipple and the baby is positioned upright as we just discussed. The bottle is positioned horizontally to the baby’s facial area. You stroke the baby’s lips with the bottle nipple. When the baby opens the mouth, you roll the bottle nipple into his or her mouth. With a newborn, you allow the baby to pause after 4 or 5 suckles by tipping the bottle. As the baby gets older, the sucking bursts will be longer. With paced bottle-feeding, parents learn to follow their baby’s hunger cues which is a terrific early communication experience.
In my book, I talk about how to find an appropriate bottle nipple, how to help the baby get a good latch on the nipple, and what to do if liquid is flowing too fast or too slowly. I also help parents think about “what to try” if the baby is having trouble feeding and what their baby’s bodies are communicating during the feeding process. Additionally, we discuss nutrition and hydration.
However, breastfeeding is biologically normal and far superior to bottle feeding based on research. Some of the advantages of breastfeeding include improved overall face, mouth, tooth, head, body, and speech development. Breastfed children are healthier and have fewer respiratory illnesses than bottle-fed children. If you think about it, no other animal is bottle-fed unless there is a medical reason or the mother is unavailable.
TS: When and how should children graduate from bottles?
DB: I have a checklist along with a detailed description of bottle and breast weaning in Chapter 6 of my book (pp. 188-192).
-Between 4 and 6-months of age, parents introduce their babies to sips from an open cup containing formula, breast milk, or stage-one baby foods thinned with boiled water (if OK with the pediatrician)
-Between 6 and 9-months of age, parents continue to provide open cup experiences and begin teaching straw-drinking with the same liquids using a straw bottle
-Between 9 and 12-months, parents continue open cup and straw-drinking experiences and can introduce a recessed lid cup. Most children have learned to drink from a straw cup at this time, so fewer bottles are offered throughout the day.
-Between 12 and 15-months, the bottle is only given at nighttime before bed while the child is sitting upright (bottles should never be given in bed for the reasons we discussed earlier regarding the orientation of the Eustachian tubes)
-Most children are weaned from a bottle by 15-months. Breast feeding may continue longer than 15-months.
TS: What are your thoughts on straws?
DB: As you know, I think straw-bottles should be introduced around 6-months of age. I have an 8-step process in my book to help parents teach their children to drink from straws (pp. 173-176). I tell parents how to make or buy a straw bottle. It is a flexible/squeezable bottle with a straw made from plumbing or refrigerator tubing (pp. 172-173).
The parent usually places thickened liquid in the bottle and carefully squeezes the bottle to make the liquid rise up into the straw. The straw is placed just onto the baby’s lips, not into the mouth onto the tongue, because we want the baby to learn to drink properly from a straw using just the lips. If you place the straw onto the baby’s tongue, the baby will drink from it like a bottle.
You start by giving the baby one sip from the straw bottle at a time until the baby gets “the hang” of sucking liquid through the straw. Between 9 and 12-months, many babies are able to drink from regular straw cups on their own. The problem is that many straw cups are labeled by the manufacturer as 2-year-old cups when much younger babies can use these.
TS: What are your thoughts on sippy cups?
DB: I prefer straw cups because sippy cups are used more like bottles in terms of mouth movement. When you observe a child drinking from a sippy cup, you often see front-back jaw movement like you see when a child drinks from a bottle. If you watch a child drinking properly from a straw (where the straw is placed only on the lips) you will see up-down jaw movement like we use during sucking.
As we discussed earlier, children begin to demonstrate the mature swallow where the tongue tip initiates the swallow on the gum ridge behind the top front teeth around 12-months of age. If a spout is placed into the mouth onto the tongue, the tongue cannot lift to the gum ridge for the mature swallow. Immature swallowing patterns often leave food and liquid lying around the mouth which then can lead to tooth decay and gum disease. This is one reason many dentists don’t recommend sippy cups.
TS: How do professionals help parents reconcile the convenience of well-contained liquids with what is best for oral-motor health?
DB: Today, you can find no-spill straw cups that are small enough for 1-year-old children (despite many being labeled for 2-year-olds). Therefore, parents don’t need to use sippy or spouted cups if they don’t choose to use them. If they choose to use them, I suggest limited use for the reasons we have previously discussed. It is important for children to have all types of cup and straw-drinking experiences for good mouth development.
TS: You have a wonderful website and networking program for families and related professionals called “Ages and Stages” that provides resources for feeding, speech, and mouth function. Would you talk to us about this?
DB: As previously mentioned:
-Our mission is to provide the best possible feeding, speech, and mouth development information for families and professionals. We do this through blogs, Q & A’s, and other formats.
-Our goal is to prevent feeding, speech, and mouth development problems when possible by helping parents keep their children “on track” developmentally through the application of evidence-based feeding information. As a speech-language pathologist, I have worked with many children who have disabilities, but I noticed that parents of typically developing children also needed the information we have (as feeding therapists) to keep their kids “on track.”
TS: You also have a number of publications and host trainings. Would you tell us about these projects and how to access them?
DB: In addition to my two books, I have written a number of journal and popular articles for parents, families, and professionals. These are listed on my website.
On my site, I also have a free E-Course on the topic of newborn and infant mouth development entitled Everything You Need to Know about a Baby’s Mouth for Good Feeding, Speech, and Mouth Development. The course is particularly useful for new parents and professionals who work with new parents, because it talks about avoiding many of the pitfalls that occur during the first year of life.
As we discussed in our last interview, a significant amount of mouth development occurs during the first year of life (particularly in the first 6-months). This is when the mouth and nasal areas are being formed for life. Many children, particularly those who are bottle fed, develop high narrow palates (roofs of the mouth) and small nasal airways during this time. Small nasal airways can lead to many upper respiratory problems including sleep apnea. I talk about how to avoid this and other problems in the E-Course.
While the E-Course was originally developed as a continuing education course for professionals, it’s presented in such a way that parents and care providers can understand and benefit from it. Information on all of my projects can be found on my website.
TS: Finally, as we close our show, would you list your top “Five Fabulous Facts for Families?”
DB: Here are some things that I would like families to keep in mind:
-Work closely with your child’s pediatrician. But, don’t expect the pediatrician to know everything about every topic, as he or she is your child’s general physician.
-Always speak with the pediatrician about the methods and resources you are using. In this interview, I am giving you educational information, not medical advice. Get your medical advice from your child’s pediatrician and other doctors.
-Be proactive and informed by getting the information you need when you need it from accurate resources. For example, my book is not a cover-to-cover read. You use it as you need it by looking up information by age or topic. We have a free age guide and topic guide for the book on our website to help you with this process.
-It’s overwhelming to be a parent these days, as there is just so much information available to parents. Many parents don’t have their own parents available to help them with what they know about child rearing. So, I encourage parents to trust their own intuition and judgment when making decisions about methods they choose once they have done their homework in finding the best possible resources.
In closing, I would like to THANK YOU, Dr. Signorelli, for giving me this opportunity to speak with parents about feeding on your wonderful radio show!
Bahr, D. (2010). Nobody ever told me (or my mother) that! Everything from bottles and breathing to healthy speech development. Arlington, TX: Sensory World.
Permission granted by Dr. Teresa Signorelli of Kids A to Z with Dr. T for printing this summary of the radio interview with Diane Bahr.