In this two-part post we will explore the factors affecting pediatric feeding intervention. Part 1 focuses on the normal progression of feeding development and the factors affecting the feeding process.
Although pediatric feeding difficulties are often viewed as a concern to be addressed by speech language pathologists, they also fall within the scope of practice for occupational therapy. In fact, the American Occupational Therapy Association even offers a Specialty Certification in Feeding, Eating, and Swallowing. As a result, this is an area that occupational therapists should be aware of and familiar with. It is even applicable for occupational therapists who work primarily with adults as feeding difficulties may also arise following neurological injuries later in life.
The Development of Feeding Skills
The normal development of feeding skills occurs rapidly over the first two years of a child’s life. The suck-swallow reflex develops at around 28 weeks of gestational age and allows the infant to begin consuming a liquid diet of breast milk or formula by suckling immediately after birth. At around three or four months of age, true sucking starts to develop. By five months, infants can begin some bite patterns, and by six months a more controlled bite pattern is developing. Infants often begin eating pureed foods around this age. By nine months they are generally eating more soft foods and mashed foods with a chewing pattern and are often learning how to sip from a cup. At around twelve months, chewing is progressing and many infants will begin weaning off of breast or bottle feeding. By 18 months, the now toddlers will generally be able to chew coarsely chopped foods and should be fairly skilled at drinking from a cup. And by 24 months, toddlers should be able to eat most foods except for those that are very tough and require extensive chewing.
Swallowing
The process of swallowing occurs in multiple phases. The first phase is the oral preparatory phase. This phase is voluntary and consists of converting the food to a bolus through use of the various structures of the mouth. Next is the voluntary oral phase where the tongue rises in the oral cavity and pushes the bolus towards the back of the throat. This is followed by the involuntary pharyngeal phase in which the airway closes and the bolus moves through the back of the throat. Lastly, the involuntary esophageal phase moves the food through the esophagus and into the stomach.
Food and Liquid Properties
Food itself comes in a variety of forms and is classified into six different textures—pureed, junior or course pureed, wet-ground or mashed, soft or dissolvable, chopped or soft solid, and full diet. These textures can either occur naturally as a result of food preparation (such as occurs in the canning of fruits and vegetables) or they can be achieved through chopping or pureeing. Liquids come in three different forms—thin, nectar, and honey. These forms can also occur naturally (as in the case of fruit nectars or honey) or they can be achieved through use of a thickening agent.
Cranial Nerve Involvement
This entire feeding process relies heavily on the cranial nerves. Cranial nerve V transmits sensory input from the mouth, and cranial nerve VII transmits motor information to the mouth. Cranial nerve VII and IX transmit sensory input from the tongue and cranial nerve XII transmits motor information to the tongue. Cranial nerve V transmits sensory input from the jaw, and cranial nerve V transmits motor input from the jaw.
In the second half of this post, we will build on this foundational background information to discuss some of the evaluation and intervention considerations for pediatric feeding process.
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