Health Sciences

ORAL SENSORY INTERVENTIONS FOR CHILDREN WITH DYSPHAGIA

Birth to Two years

Clinician Handbook with CD-Rom

Acknowledgements

This booklet has been created as part of a final year Speech Pathology project at La Trobe University by:

Lyndal Cockrum, Fleur Duband, Bobbie Hall, Catherine King, Rebecca Lamont and Rachael Lew

With the guidance of: Justine Slattery (La Trobe University) and Cara Naughton (Northern Health)

We would like to thank the parents and external clinicians who contributed to this booklet and CD-Rom.

Special thanks to Tim Martino for the graphics.

ORAL SENSORY INTERVENTIONS FOR CHILDREN WITH DYSPHAGIA

BIRTH-TWO YEARS

Table of Contents

Introduction

The aim of this booklet is to provide clinicians with an accessible and practical tool to facilitate oral sensory interventions. This booklet is designed to provide clinicians with the rationale and evidence behind different interventions.

The attached CD-Rom provides informational fact sheets for your distribution to parents/caregivers of children with feeding difficulties associated with oral sensory impairments.

NORMAL ORAL SENSORY DEVELOPMENT

Introduction to Normal Oral Sensory Development

A child’s ability to acquire functional feeding skills relies upon the integration of sensory and motor systems in conjunction with neurological developments. For example, oral reflexes present at birth (as described in Table 2) are triggered by sensory stimuli, and most aspects of the resultant reflexive movements provide important oral sensory feedback to the infant (Morris & Klein, 2000).

As the number of sick and pre-term infants surviving continues to increase, so too does the occurrence of paediatric feeding difficulties (Dodrill, McMahon, Ward, Weir, Donovan, & Riddle, 2004; Hawdon, Beauregard, Slattery & Kennedy, 2000). Not only is there a high incidence of feeding difficulties in neo-natal intensive care units, but studies have also identified that future feeding developments in these children are more likely to be adversely affected (Dodrill et al., 2004; Hawden et al., 2000).

Importance of Oral Sensory Receptors

Sensory receptors are structures in the nervous system that respond to specific changes in their environment (Marieb, 2001). Stimulation of the oral cavity takes many forms, thus, it is detected by a wide range of sensory receptors. When tissues of the oral cavity are altered by forces such as touch, pressure, stretch, vibration and itch, mechanoreceptors are activated and generate sensory nerve impulses (Marieb, 2001). This type of stimulation may take place during oral exploration, caregiver interaction and oral feeding. Specific information about smells and tastes are detected by chemoreceptors. Thermoreceptors detect changes in temperature, such as the temperature of liquid or solids during feeds, whilst nociceptors detect potentially damaging stimuli that result in pain (Marieb, 2001).

Whilst oral sensory receptors are activated throughout the day, they play a crucial role in determining the safety and enjoyment of oral feeding. The development of a child’s oral sensory receptors allows a healthy newborn to immediately locate and tolerate breast or bottle feeds. These oral sensory receptors are the earliest to emerge in foetal development and are crucial in assisting an infant to thrive (Morris & Klein, 2000).

Oral Sensory Development

Anatomical and physiological developments of the foetal upper aerodigestive system are associated with the development of observable intrauterine behaviours such as suckling and swallowing (Miller, Sonies & Macedonia, 2003). Successful developments across a basic-to-complex continuum, act as prerequisites for post-natal survival skills in the extrauterine environment (Miller et al., 2003). The importance of well developed feeding skills at birth is evident in preliminary data provided by Dodrill et al. (2004). Low-risk pre-term infants born between 32-37 weeks that required greater than 3 weeks of supplemental tube feedings, demonstrated an increased occurrence of continued altered oral sensitivity, facial defensiveness with associated negative behaviours and delayed feeding development at 11-17 months corrected age.

The curled position of the foetus in utero allows for the use of flexor motor patterns. Such patterns as hands to mouth followed by mandibular movements are suggestive of early thumb-sucking before birth (Birnholz, Stephens & Faria, 1978). These flexor patterns remain present at birth, and the generalised flexor tone aids flexor skills such as lip seal, sucking and early mouthing activities (Morris & Klein, 2000).

In the first few months of life, the sheer size of an infant’s tongue provides ongoing sensory feedback regarding the shape and movement of the mouth, due to its confinement in a relatively small intraoral space (Bosma, 1967, as cited in Morris & Klein, 2000).

In the following months, further neurological development and growth of the lower jaw occurs. The expansion of inner-mouth space enables the tongue to contact a wider range of intra-oral surfaces, thus receiving a greater range of sensory feedback (Morris & Klein, 2000). Oetter, Richter & Frick, 1988 (as cited in Morris & Klein, 2000) suggest that non-nutritive sucking also contributes to the organisation of the sensory system.

Critical and sensitive periods play a role in the development of behavioural and sensory feeding problems. Skuse (1993) suggests that sensitive periods for the introduction of food/fluid taste and textures exist. In these sensitive periods (4-6 months for taste and 6-7 months for solids) infants are more accepting of exposure to these new stimuli.

Infants who are not given or are unable to receive these opportunities tend to be resistant to new tastes and textures in later childhood. Aversive and hypersensitive responses to oral stimuli may also occur due to lack of oral stimulation concurrent with non-oral feeding in hospitalised infants. Infants unable to engage in normal developmental exploration can have dramatically reduced sensory input and perception in the mouth (Skuse, 1993). Therefore, the Speech Pathologist’s role is to reintroduce these sensitive periods and crucial stages of normal development in a manner the infant or young child can tolerate (Wolf & Glass, 1992).

Oral Sensory Experiences

Exposure to a wide range of oral sensory experiences plays a fundamental role in oral sensory development and feeding skills. Early mouthing activities enable infants to discover a range of oral sensations, including variations in taste, surface texture, touch, pressure, temperature, size and shape (Arvedson & Brodsky, 2002). As a result, normally developing infants learn to tolerate, detect and respond appropriately to a growing range of oral sensory experiences, that then promote transition from breast or bottle feeds to solids and cup drinking.

Table 1. Critical Periods & Sensory Milestones

Pre-Term

• Oral sensory receptors developing (Marieb, 2001)
• 7 weeks- Tastebuds are evident allowing early pre-birth experiences of amniotic fluid flavour changes in line with the mother’s dietary choices (Arvedson, 2006; Mennella, Jagnow & Beauchamp, 2001).
• Flexor motor patterns including hands to mouth followed by mandibular movements are suggestive of early thumb-sucking (Birnholz, Stephens & Faria, 1978).
• Child engages in behaviours that stimulate the suck/swallow reflex including suckling or mouthing of fingers, hands, extremities, umbilical cord or placenta (Miller et al, 2003).

0-6 months old

• Breastmilk or formula feeds (Fraker & Walbert, 2003)
• 0-3 months- Sensory input including breast or bottle, pacifier, fingers and other objects such as toys important for developing coordinated sucking and swallowing (Orr & Allen, 1986)
• 0- 3 months- Infant’s tongue provides ongoing sensory feedback regarding the shape and movement of the mouth (Bosma, as cited in Morris & Klein, 2000).
• Non-nutritive sucking contributes to the organisation of the sensory system (Oetter, Richter & Frick, as cited in Morris & Klein, 2000).
• Suck/swallow/breath sequence present at birth progressively becomes more established (Orr & Allen, 1986).
• 4-6 months acceptance of new tastes (Skuse, 1993)

6-12 months old

• Breastmilk or formula feeds (Fraker & Walbert, 2003)
• 6 months- Introduce baby food and spoon and cup feeding (Fraker & Walbert, 2003)
• 6-7 months- Introduce solids that require chewing (Skuse, 1993)
• 8-9 months- Introduce semi-solids (Fraker & Walbert, 2003)
• 9 months- Introduce soft-solids (Fraker & Walbert, 2003)

12- 24 months old

• 12 months- Introduce whole cow’s milk. Offer a variety of soft foods and introduce child to mixed textures. Child begins to self feed and hold own cup.
• 15 months- Introduce solids (coarsely chopped)
• 18 months old– Coordinated hand to mouth skills
• 24 months old- Mature chewing and drinking skills (Fraker & Walbert, 2003)

Table 2. Oral reflexes at term in response to early sensory input

Adapted from (Arvedson & Brodsky, 2002, Chapter 2)

Table 3. Neurodevelopmental progressions of sucking response

Adapted from a literature review (McGrath & Braescu, 2004)

Sensory based feeding problems

What is Dysphagia?

Dysphagia is the term that refers to the difficulty in swallowing. It encompasses the difficulty in the passage of solids and/or liquids from the mouth to the stomach. Dysphagia may affect the oral, pharyngeal, or oesophageal phases of the swallow. Optimum nutrition is extremely important, especially in the paediatric population. Dysphagia can limit a child’s nutritional intake and this can subsequently impact on an infant’s health and growth.

Who is at risk?

Dysphagia in the paediatric population is prevalent and can occur as a result of a number of aetiologies including structural, neurological and or behavioural aeitilogies (Arvedson, 2006).

What are the links between oral sensory impairment and dysphagia?

The links between oral sensory impairments and dysphagia are significant. In particular, difficulties relating to an infant’s sensory development and processes have a significant impact on their swallow. Factors that contribute to sensory based feeding problems include lack of appropriate oral stimulation (i.e. failure to stimulate at critical periods, long term non oral feeding) and/or inappropriate or negative oral sensory experiences. Specific patterns of neurological impairment with damage to cranial nerves may also play a role (Morris & Klein, 2000).

The characteristics of infants with sensory based feeding problems have been described in the literature. They suggest that these difficulties can occur along a continuum, and can be specific to oral sensoriomotor function that is part of more systemic difficulties integrating and processing sensory information (Morris & Klein, 2000). Behaviours consistent with sensory based feeding problems include head turning, expulsion of food/fluids, gagging, crying, food/fluid refusal, and body rigidity in response to food/fluids or feeding tools.

Sensory limitations that may affect a child’s swallowing ability include:

Absent Responses:

if an infant does not respond to tactile and/or sensory stimulation, non-oral feeding may be required.

Hyposensitive Responses:

child needs large amounts of stimulation to elicit required response. Responses are often slow or incomplete resulting in inadequate lip closure, poor bolus manipulation, and decreased swallow trigger due to reduced pharyngeal sensitivity.

Hypersensitive Responses:

child has heightened response in proportion to magnitude of stimuli. Responses are often very quick and exaggerated, for example, a gag response elicited when tongue tip is touched by nipple of bottle teat.

Aversive Responses:

child has a stronger and more negative response to oral stimuli (stronger than hypersensitive responses), and generally involves a behavioural component such as crying, arching away, keeping mouth closed, gagging or vomiting. This aversive response can be triggered upon visual recognition of feeding tool. (Wolf & Glass, 1992)

Who is involved?

Ideally Speech Pathologist working with the paediatric dysphagic population will be members of an inter-disciplinary team. The team should consist of experts from various disciplines to ensure effective assessment, diagnosis and coordinated treatment e.g. Occupational Therapist, Paediatrician, Nurse, Psychologist and Dietician (Simonsmier & Rodriguez, 2007). Regardless of the health professionals involved, it is important that the team treat any medical condition, employ behavioural modification to alter the child’s incorrect- learned feeding patterns and provide high levels of parent education, training and support (Manikam & Perman, 2000).

NORMAL ORAL SENSORY DEVELOPMENT

What is it?

During mealtimes the sensory environment can have an impact on the feeding process in many ways, affecting both the child and the parent. The sensory environment includes light, visual stimuli, noise and parent/child positioning. Making small modifications to the sensory environment can make mealtimes more positive experiences for both the child and the parent (Wolf & Glass, 1992). The changes may aim to: alert the child to the feeding process, rather than the sensory environmental variables; reduce over stimulation; and create a calming environment.

Who is it used for?

Children and parents will be affected by their immediate sensory environment during mealtimes in various ways depending on their physical, sensory, cognitive, and emotional needs. (Morris & Klein, 2000). For the child with sensory processing deficits, the sensory environment during feeding can be therapeutically arousing, or uncomfortable and stressful (Case-Smith, 1980). Sensory environment modification is used to make mealtimes more relaxing, comfortable and enjoyable for both the child and parent.

Rationale

Children attend to the sensory environmental variables that are the strongest or most alerting before responding to the neutral variables (Morris & Klein, 2000). For example, if there is loud music or bright light, the child may focus on this instead of the meal. Neurologically impaired infants may be unable to cope with competing sensory environmental stimuli and may have difficulties in achieving an integrated organization of the nervous system (Arvedson & Brodsky, 2002). Therefore, the child is likely to be uncomfortable and stressed during mealtimes if there are competing sensory environmental variables.

Correct positioning is very important during mealtimes. It can reduce abnormal movements and create internal stability, which enables more functional and fine motor control required for feeding (McCurtin, 1997).

The child’s vestibular system is affected by positioning. This system receives sensory information regarding the pull of gravity on the central axis of the body and this can create changes in muscle tone (Morris & Klein, 2000). If a child is positioned in a vestibular alerting posture (i.e. head slumped forward and tilted to one side, feet dangling) the child will attend to the vestibular system rather than the meal (Morris & Klein, 2000).

The child should always be positioned in a stable and supported position during mealtimes. The child’s joints, muscles and tendons provide proprioceptive sensory information about what the muscles are doing at a point in time. Proprioceptive information is needed to make postural adjustments, to maintain adequate muscle tone and to execute smooth motor patterns for feeding (Morris & Klein, 2000). Thus, correct positioning during mealtimes achieves optimal body tone and creates smooth motor patterns for feeding.

When positioning a child it is also important to consider the tactile sensory information the child is receiving. This can include texture, light/deep touch, pain, temperature and vibration. Tactile sensory information can draw the child’s attention towards or away from mealtimes. For example, light touch may distract a child and deep pressure touch may calm a child (Morris & Klein, 2000). Tactile sensory information can be used to prepare a child for mealtime and to help focus attention.

Activities

Environmental modifications include adapting the child’s visual stimuli. This includes modifying the colour of the child’s surroundings and utensils, in addition to ensuring the light is appropriate.

Background noise can have both a positive and negative impact on a child’s feeding abilities. Loud background noise can compete with the child’s attention, whilst rhythmic or slow background music can enhance a child’s feeding.

The optimal position of each child is not always the same, however it is crucial that all children are well supported and stable. Usually, a child’s position should be modified to ensure that:

• the child is in the flexed upright position
• their head and neck are aligned with their body
• their shoulders are symmetrical and forward

Physiotherapist and Occupational Therapist colleagues will be consulted regarding specific postural/positioning changes.

For more ideas, please see the ‘Sensory Environmental Modifications’ Fact Sheet on the CD-Rom.

SENSORY PLAY

What is it?

Sensory play is used by children to explore themselves and their environment. The first few years of life offer new experiences with every sense, each day. Therefore, it is an essential activity for children’s development to allow this exploration to occur.

Who is it used for?

Sensory play is an integral part of development for all children. It allows them to explore the world through sight, sound, touch, smell and taste.

Rationale

Tactile-sensory play helps:

• fine motor skills (hand-eye co-ordination)
• creativity
• emotional development (tension release and confidence building)

(Duffy, 2007)

Occupational therapists focus on developing these skills with children with oral sensory problems, as well as children with disorders of global sensory defensiveness.

Smell awareness can warn us of dangers and sharpens our awareness of other people, places and things (Cone, 2007). It can also be a fun experience learning about the world of smell.

Activities

Tactile-sensory play can use a range of different materials, such as: shaving cream, paint, water, sand, uncooked rice, bubbles, play dough or clay in a variety of activities. These could include finger-painting, face painting, or other activities involving materials of varying texture (Cone, 2007; Funk, 2008; Play and learning program, 2003).

Smelly play can be implemented through both non-food and food products such as flowers, toothpaste, scented candles or soaps (during bath time), vegemite, mint, jams, fruits or other fragrant materials (Lambe, 2007).

Materials for sensory play can be easily found at any supermarket or around the house, and can be simple to prepare. Even allowing a child to get dirty playing in the garden or during bath time are sensory play activities.

For a more complete activity sheet, please see the ‘Sensory Play’ Activity fact sheet.

MESSY PLAY

What is it?

Messy play is a significant oral-sensory intervention for paediatric dysphagia. It focuses on the exploration of new foods through tactile, smell and taste sensory stimulation (Duffy, 2007). Messy play familiarises a child to different textures, temperatures, smells and tastes. Children need repeated exposure to new foods before they are comfortable eating them. Through messy play children can observe and manipulate varying materials/food to identify features, similarities and differences using all of their senses Therefore, becoming more aware of their environment (Duffy, 2007; Play and learning program, 2003).

Who is it used for?

Messy play can be used for children with oral hypersensitivity, tactile defensiveness or food aversion. These children typically avoid messy play therefore, it is an effective technique in reducing fear of new foods, and play is a key facilitator of learning (Sanghara, 2002).

Rationale

According to Douglas (2000, p.147) Messy play helps to:

• desensitise the child’s fear of new food and change
• build up the child’s confidence and self-esteem about trying new foods
• increase the range of foods eaten in a gradual and unthreatening manner
• reinforce the child’s success at trying and accepting new and different foods
• maintain the child’s weight and growth

Activities

Messy play can involve different textures such as yoghurt, vegemite, fruit jam, cooked rice, cereals, fruits, dry biscuits, lumpy mash potato or spaghetti. It also consists of squeezing or crushing bits of food, making cookie dough or a cake and other activities involving food manipulation (Play and learning program, 2003).

In addition, messy play can involve modifying the temperature of the food items used (i.e. playing with ice or ice-cream, or cooked macaroni and vegetables).

For a more complete activity sheet, please see the ‘Messy Play’ Activity Fact sheet.

ORAL EXPLORATION

What is it?

Oral exploration is a treatment technique used for infants and children to normalise responses to sensory stimulation in and around the mouth and face, and improve feeding and swallowing abilities (Wolf & Glass, 1992). Oral exploration is a direct therapy approach for improving oral sensorimotor function in infants and young children with feeding and swallowing difficulties. Oral exploration involves the clinician, parent/caregiver providing pleasurable oral and facial input using a variety of stimuli including the clinician/parent’s fingers, the child’s fingers or hands, toys or dummy. The therapy provider assists the child with mouthing various objects and adjusting the frequency and duration of the stimuli according to the child’s limits (Wolf & Glass, 1992).

Who is it used for?

According to Wolf and Glass (1992), mouthing of toys and hands is a critical component of oral exploration needed for oral normalisation in the infant. Infants explore the environment through the mouth improving their ability to tolerate a variety and increasingly complex oral sensations such as solid and textured foods.

Infants are unable to engage in normal developmental oral exploration due to factors such as:

• immaturity and illness
• unpleasant oral-tactile experiences
• delayed introduction of oral feeding
• reduced/absent experiences due to sensorimotor difficulties or parenting styles and beliefs

This population is at risk of developing a hypersensitive or aversive response to oral stimuli (see page 16 for definitions). These responses may not be confined to touch and may include aversive or hypersensitive responses to taste, temperature, smell or texture (Wolf & Glass, 1992).

Rationale

Orr and Allen (1986) suggest that feeding and other development skills can be affected by the lack of oral experiences during critical and sensitive periods. Infants denied oral feeding/stimulation and the correct introduction of taste and texture are more likely to develop abnormal responses that interfere with normal oral sensory development.

Activities

Oral exploration can involve the use of fingers, toys, or vibration. A variety of mouth-toys are available, ranging from smooth to textured surface properties (i.e. spikey or bumpy). Some examples of safe equipment that can be incorporated into an oral exploration program includes: the ‘Nuk’ massage brush and ‘Chewy Tubes’ from SenseAbilities. This can be found at:

http://www.senseabilities.com.au/index.cgi?tid=5&range=00)

Please see the ‘Oral Exploration’ Fact sheet on the CD-Rom for more specific activity ideas.

ORAL DESENSITISATION

What is it?

Oral desensitisation is an intervention that aims to reduce the child’s hypersensitive or aversive response to stimuli using non-threatening exercises. These can include grading levels of touch, firm pressure, or the application of vibration to the child. Vibration can be delivered using hands, vibrating toys or toothbrushes.

Depending on the child’s level of sensitivity, desensitisation techniques often need to be presented to areas distal to those that are most sensitive. For example, the child may need firm pressure applied to their limbs and trunk before presenting the stimuli to the head.

Who is it used for?

Oral desensitisation is an intervention often used when children display oral hypersensitivity or negative responses to food. These responses include gagging or refusal of the breast, bottle or dummy.

Rationale

Scarbourough et al. (2006) noted that children who have feeding difficulties often display an increased sensitivity to touch. Subsequently, these children often have reduced oral exploration (Starr, 2006). As discussed in ‘Oral Exploration’, this can negatively influence their oral and feeding skills. According to Scarbourough et al. (2006), positive touch experiences reduce the likelihood of a child displaying hypersensitivity to oral input.

Vibration accesses a different neurological pathway compared to touch and pressure. As a result, it is less likely to stimulate a negative response to oral exploration (Wolf & Glass, 1992).

According to McCurtin (1997), hypersensitive children respond more appropriately to firm pressure than light touch. This increased tolerance can then be utilised during therapy to reduce the child’s negative responses.

Activities

The type of intervention utilised will be dictated by each child and their responses to sensory stimuli. If the child displays anxiety or stress, revisit the previous stage that the child was comfortable with.

Vibration, firm pressure and massage can be used in a graded intervention:

1. Begin distal to the sensitive area, applying slow, gentle, yet firm strokes to less sensitive areas of the body (arms, legs and torso).
2. Move towards the head, keeping to the outside of the mouth (i.e. cheeks, chin and lips).
3. Gradually move into the mouth starting at the midline of the gums, moving backwards. Then proceed further into the mouth towards the hard and soft palate.

Note: a range of textures and tools can be used such as fingers, dummies, velvet, vibrators and toothbrush trainers.

Some of these items can be found at:

• www.therapybookshop.com
• http://www.tommeetippee.com.au/category.asp?pk=1
• http://www.theraproducts.com/index.php?main_page=categories

MODIFICATION OF THE SENSORY PROPERTIES OF FOOD

What is it?

Changing the sensory stimulation that a child receives during feeding by altering the properties of food, through food choices and preparation. Sensory properties of food include visual (shape, colour), auditory (noise produced by cutting food, biting, chewing and moving around mouth), tactile (surface texture, consistency, firmness, size), temperature and taste (flavour).

When a child receives food, they are presented with a stimulus that can under, over or appropriately stimulate their sensory system. Modifying the sensory properties of food to the level of stimulation required by the child, aims to reduce over or under-stimulation during feeding. This may increase the amount and types of food a child tolerates, as well as reducing the corresponding negative physiological and behavioural responses of the child at mealtimes.

Who is it used for?

This technique can be used for children with sensory integration disorders at either end of the sensitivity spectrum. Those demonstrating negative reactions to feeding due to over-stimulation, may benefit from reducing the variety or strength of sensory stimuli presented at mealtimes. Sensory stimulation for these children may be interpreted as highly noxious (Morris & Klein, 2000). The child’s response to sensory information is exaggerated and out of proportion to the magnitude of the stimuli (Wolf & Glass, 1992).

In contrast, children with hyposensitive or absent responses to the range of stimuli provided during feeding may respond to increased sensory information. Modification of the sensory properties of food aims to enable safe, effective and enjoyable feeding experiences for the child.

Rationale

Feeding and swallowing development relies on the intricate relationship between a child’s environment and the development of their physiological and neurological systems (Rogers & Arvedson, 2005). Some children have difficulty processing and integrating sensory information, changing their feeding experiences (Morris & Klein, 2000).

Human perception of feeding events begins with the detection and processing of sensory information. The tastebuds of a foetus are evident by seven weeks gestation. This allows pre-birth experiences, such as the detection of flavour changes in amniotic fluid with the mother’s dietary choices (Arvedson, 2006; Mennella et al., 2001). The degree of sweetness in amniotic fluid appears to be an important type of sensory input for infant feeding (Burke, 1977). Weiffenbach & Thach, 1973 (as cited in Arvedson & Brodsky, 2002), demonstrated that the addition of sucrose to formula or water aided the elicitation of suck-and-swallow patterns in infants.

The ability to detect additional flavours and tastes continues to develop after birth (Arvedson, 2006). Other sensory information from food such as smell and visual appearance can influence the child’s perception of a feeding experience before food even reaches their mouth.

Once in contact with the mouth, judgements are made on the structure of the food, how it feels as it is broken down and whether it can be consumed safely (Rosenthal, 1999). The importance of introducing various textures within critical and sensory timeframes promotes acceptance of chewable food, and has been discussed in the literature (Arvedson, 2006). A child’s chewing skills may vary across different textures (Arvedson, 2006). Children’s chewing patterns usually mature earlier for solid foods than those that are viscous or pureed (Arvedson, 2006).

This sensory feedback from the oral cavity involves a wide range of specialised receptors including mechanical, proprioception, chemical, pain, taste, smell and temperature (Rogers & Arvedson, 2005). It has been found that sensory information such as textural properties and flavours frequently contribute to the acceptance or rejection of food (Rosenthal, 1999; Mennella et al , 2001; Arvedson, 2006). A child’s perception of the stimulation and the feeding process as a whole is also determined by their past experiences (Rosenthal, 1999).

Activities:

There are a number of ways to increase or decrease the stimulation that a child perceives around feeding times. This can be achieved through adjusting the auditory, olfactory, visual, temperature, textural or taste elements of food, as well as manipulating the child’s positioning for adjusting vestibular feedback.

Please see the ‘How do I Increase/Reduce Information Available at Mealtimes’ fact sheets on the CD-Rom for specific activity ideas. Additional parental information can be viewed at:

http://new-vis.com/fym/p-feed.htm

MEALTIME INTERACTIONS USING BEHAVIOUR MODIFICATION

What is it?

Mealtime relationships can greatly impact on therapy. Focusing on mealtime interactions will facilitate a more positive environment for improved feeding.

Behavioural interventions may be useful in addressing feeding difficulties by either increasing or decreasing the behavior (Swigert, 1998). This is achieved through the use of positive and negative reinforcement, extinction, differential reinforcement, punishment, boundaries, and routines.

Who is it used for?

Many children with dysphagia can develop an experiential or behavioural component to their feeding difficulty (Morgan & Reilly, 2006). There is a continuum on whichdifficulties occur. Feeding difficulties can range from purely behavioural aeitilogies to anatomical and /or physiological impairments.

According to Swigert (1998), behavioural feeding difficulties can present as:

• the child not reaching their predicted weight/height thresholds
• parents ‘fighting’ their child during feeding
• extremely long mealtimes
• the child often gagging or vomiting during a mealtime
• high selectivity regarding food

Rationale

It is important to address behavioural feeding difficulties as they can greatly impact a child’s oral intake, in addition to disrupting the mealtime routine (Morgan & Reilly, 2006). Long term inappropriate or negative feeding experiences can lead to inappropriate behaviours as the child acts to protect itself. It is important to reiterate this to parents, as it is not the child behaving badly, rather it is the child trying to ‘preserve’ themselves.

As mentioned in ‘Normal Oral Sensory Development’ there are critical or sensitive periods for the introduction of appropriate sensory information. A disruption in a child’s learning curve for eating and drinking could potentially occur secondary to sensory or motor issues. Subsequently creating a cycle where the child is less likely to have positive experiences with new sensations.

Activities

Interventions that aim to maximise optimal feeding behaviours shape the child’s responses with positive and negative reinforcement. Interventions also focus on decreasing negative feeding behaviours. These include extinction, punishment and differential reinforcement.

Parents may find it useful to set up feeding routines and rules. Chatoor’s food rules can be used to facilitate this (Chatoor, Dickson, Schaefer & Egan, 1985).

Useful tips for mealtimes can also be found at Ellyn Satter’s website:

www.ellynsatter.com

REFERENCES

Arvedson, J. C. (2006). Swallowing and feeding in infants and young children. GI Motility Online. Retrieved August 26, 2008 from http://www.nature.com/gimo/contents/pt1/full/gimo17.html#t3

Arvedson, J. C., & Brodsky, L. (2002). Pediatric swallowing and feeding: Assessment and management. (2nd ed.). Canada: Singular.

Birnholz, J. C., Stephens, J. C., & Faria, M. (1978). Fetal movement patterns: A possible means of defining neurologic developmental milestones in utero. AJR Am J Roentgenol, 130(3), 537-40. Retrieved June 24 2006, from http://www.ajronline.org/cgi/reprint/130/3/537

Burke, P. M. (1977). Swallowing and the organisation of sucking in the human newborn. Child Development, 48, 523-531.

Case-Smith, J. (1989). Intervention strategies for promoting feeding skills in infants with sensory deficits. Occupational therapy in health care, 6(2/3), 129-141.

Chatoor, I., Dickson, L., Schaefer, S., & Egan, J. (1985). A developmental classification of feeding disorders associated with failure to thrive: Diagnosis and treatment. In D, Drotar (Ed.), New directions in failure to thrive: Research and clinical practice. (pp. 235–258). New York: Plenum Press.

Cone, L. (2007, August 8). Sensory Play for Toddlers. California: Disney Family Inc. Retrieved August 5, 2008 from http://www.toddlerstoday.com/articles/development/sensory-play-for-toddlers

Dodrill, P., McMahon, S., Ward. E., Weir, K., Donovan, T., & Riddle, B. (2004). Long-term oral sensitivity and feeding skills of low-risk pre-term infants. Early Human Development, 76, 23-37.

Douglas, J. (2000). The management of selective eating in young children. In A. Southall & A. Schwartz (Eds.), Feeding problems in children. (pp.141–151). London:TJ International.

Duffy, B. (2007). All about messy play. United Kingdom: Crown. Retrieved July 12, 2008 from http://www.standards.dfes.gov.uk/eyfs/resources/downloads/4_3_c.pdf

Fraker, C., & Walbert, L. (2003). Evaluation and treatment of pediatric feeding disorders: from NICU to childhood. California: Speech Dynamics, Inc.

Funk, J. (2008). Wonderful water play. California: Excelligence Learning. Retrieved July 12, 2008 from http://www.earlychildhoodnews.com/earlychildhood/article_view.aspx?ArticleId=385

Hawdon, M. J., Beauregard, N., Slattery, J., & Kennedy, G. (2000). Identification of neonates at risk of developing feeding problems in infancy. Developmental Medicine & Child Neurology, 42, 235-239.

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