Feeding Therapy

COMPREHENSIVE ORAL SENSORY-MOTOR SPEECH AND FEEDING EVALUATION

Oral - motor functioning is the area of assessment which looks at normal and abnormal patterns of the lips, tongue, jaw, cheeks, hard palate and soft palate for eating, drinking, facial expression and speech to determine which functional skills a client has to build on, and which abnormal patterns need to be inhibited or for which compensation is needed. Structure (lip, tongue, jaw, cheek) affects oral motor control. Recognition of the patterns is essential to adequately attain baseline the individual's current skills, so that an appropriate plan of intervention can be developed. That plan will include mealtime interventions (positioning, handling techniques, adaptive equipment, etc.), as well as oral motor interventions to enhance control of the lips, cheeks, jaw and tongue.

Suckling vs. Sucking
(both ocurr around 6 - 9 months)

It's important to consider all of the below relfexes have on the development of the infants' swallowing skills.  For example, children with neurological impairments may have some impaired reflexes and so on.  From 4 - 6 months, infants receive all their nourishment through nipple feeds. The change from nipple feeds to transitional feeding is related to central nervous system maturation.  The terms Sucking and Suckling often get confused yet are very important milestones to understand.  Below is a chart descibing the difference for the main oral structures.

Suckling

Tongue: -Backward and forward motion of the tongue-Tongue does not protrude past lips -Front of tongue, with lips, seals against nipple.  Back of tongue seals against soft palate to keep liquid in mouth until child is ready to swallow -Tongue is flat, thin, cupped, or bowl shaped.
Jaw:-Moves up & down
Lips:-Loose approximation on nipples
Cheeks:-Fat pads provide stability & keep food from accumulating in buccal cavities.
Hard Palate:-Tongue presses against palate during forward & backward motion
Soft Palate:-Seals against back of tongue to keep liquid in mouth -Lifts during swallow to seal nasopharynx to prevent liquid from entering the nasal cavity
 

Sucking

Tongue: -Tongue body raises and lowers -There is more room for tongue movement because oral cavity has grown down and forward.-Tongue is flat, thin, slightly cupped, or bowl shaped.
Jaw:-Moves up & down less but still helps produce suction (negative pressure)
Lips:-Tight approximation on nipple helps seal & stabilize it in the mouth.
Cheeks:-Continue to provide stability. -Provide boundary on either side of the tongue to keep liquid on tongue.
Hard Palate:-Tongue presses against palate to create positive pressure on nipple
Soft Palate:-Same as suckling except soft palate does not move towards tongue

 

 

Lip Patterns

There are three normal lip patterns; lip rounding, lip spreading & lip closure.

Lip rounding:The lips form a circular shape maintaining muscular tonal balance. This position is attained through easy, nonforceful movement. The amount of rounding can be varied as needed to obtain and maintain a seal around a feeding utensil, or to build up or maintain intra-oral pressure.
Lip Spreading:The lips form an expanded horizontal line from the rest position, maintaining normal muscle tone. The position is attained through easy, non-forceful movement. The amount of spreading can be varied as needed to control substances in the front of the mouth, or to aid in drawing substances into the mouth.
Lip closure:The lips meet and touch to seal off the contents of the mouth from the outside. The position is attained through easy, non-forceful movement. The amount of contact and the area of contact can be varied as needed to retain substances in the mouth.
 

Abnormal Lip Patterns

In addition to recognizing normal patterns, you should also evaluate for abnormal patterns, including lip retraction, anterior spillage, and lip purse-string, hypotonicity and asymmetrical lip movement. Each of these patterns interferes with lip closure, mouth opening and with forming a seal around a feeding utensil (bottle, straw, cup, spoon, etc.). It also affects one's ability to obtain and/or maintain intra-oral pressure.

  • Lip tremor - rapid, small movements of the lips during purposeful activity such as lip seal.  A mildly abnormal pattern indicating fatigue.  Lip retraction - This is an abnormal pattern in which increased abnormal tone pulls the corners of the lips up and back.  It may be observed to affect upper lip movement more than lower.  A person with this patter may be described as "always smiling".  The anterior cheek usually shows a retracted pattern.
  • Lip purse-string - an abnormal pattern in which the corners of the lips are pulled back as the rest of the lip pulls to midline with an increase in abnormal tone.  Increased tone may extend from below the nose to the chin and into the cheeks.
  • Assymetrical Lip Movement - one side of the lip moves with less control than the other.  Abnormal patterns and muscle tone are noted on the affected side.
  • Hypotonic lips - an abnormal pattern in which the lips appear flaccid, with little or no active movement. The lips may look puffy. The lower lip may appear more involved than the upper lip.
  • Dystonic lip movement - An abnormal pattern characterized by rhythmical, nonfunctional movement of either or both lips, associated with Parkinson's or Parkinson's like symptoms. The ability to interrupt the movement is related to the severity of the disease. With less severe involvement, the pattern can be interrupted during functional activities such as eating and speech, and will not be observed during sleep.
  •  Lip Fasciculations - An abnormal pattern of nonrhythmical, unorganized contraction of individual muscle fibers across the lips. May be observed when the lips are at rest, or following direct stimulation of the lips. May also be observed during generalized hypotonicity affecting the whole body.

Tongue Patterns

Tongue movements are an integral part of the eating process. The following six normal patterns (suckling, simple tongue protrusion, sucking, munching, tongue tip elevation and lateral tongue movements) are presented in order from primitive to more mature patterns.

  • Suckling - The primary movement in suckling is extension – retraction. The tongue does not extend beyond the lips. Lateral movement is not observed. The tongue may show a semi-bowl shape (cupping). The tongue remains flat and thin. The movement is accomplished with normal tonal changes with rhythmical cycles of extension - retraction. Jaw opening and closing occur in conjunction with tongue movement. This is a normal but primitive pattern.
  • Simple tongue protrusion - This is a primitive, normal movement associated with the suckling pattern. The tongue extends between the teeth or gums. The tongue remains flat and thin with no abnormal tonal changes. (In the normal population, this may be called tongue thrust, especially by speech pathologists.)
  • Munching - The primary movement of the tongue is up and down with flattening and spreading. Lateral tongue movements are not observed during this pattern. Tongue movements are accompanied by up and down movement of the jaw for chewing and biting. This is a normal tongue pattern observed in early chewing. Food is positioned on the body of the tongue and raised upward to the palate to break up the food prior to swallowing. Soft, lumpy foods, ground meats, and foods that dissolve in saliva (such as crackers), are tolerated with this chewing pattern
  • All of these patterns are normal, but do not involve any lateral tongue movement. The person cannot move food between molars for chewing. Since this is needed for chewing more viscous foods, s/he fails to move along the continuum of greater variety and separation of tongue, lip, and jaw patterns. The person is limited to a diet which does not require chewing and grinding, such as a pureed diet.
  •  Lateral tongue movements - The tongue moves to either side, horizontally, to shift food from the center of the mouth to the side. Initially, the tongue may barely shift toward the gum. As skill develops, the tongue will contact the gum or molars. With more control, the tongue will move over the gums or molars. With continued development, the tongue will extend into either cheek. As skills develop, the tongue can move food from one side across the midline to the other side. As movements become more defined, lateral and tongue tip elevations are combined to allow sweeping/cleaning movements of lips, palate, and inside the cheeks. This allows particles of food to be gathered and positioned on the tongue prior to swallowing.

Abnormal Tongue Patterns

  • Tongue tremor - Rapid, small movements of the tongue during purposeful activity, such as sucking. A mildly abnormal pattern indicating fatigue. May be observe in nursing infants during sucking.
  • Exaggerated tongue protrusion - The tongue shows extension (forward movement) beyond the border of the lips which is non-forceful. The movement is a rhythmical extension-retraction pattern. It is similar to a suckle pattern, but is mildly abnormal.
  • Tongue thrust - The tongue is thickened and bunched. The movement is an outward extension beyond the border of the lips. The movement is forceful, and is associated with an abnormal increase in muscle tone. This may occur as part of a total extension pattern of the body, or with hyperextension of the head and neck. The tongue thrust may make it difficult to insert a utensil into the mouth or may cause food to be ejected during feeding. During drinking, the tongue may thrust into the cup or may protrude in a very tight, bunched fashion beneath the cup.
  •  Tongue retraction - In this abnormal movement, the tongue appears thickened and bunched. The movement is retraction, a strong, pulling back of the tongue into the posterior portion of the oral cavity, associated with abnormal increased muscle tone. The tip of the tongue is not forward and even with the lower lip. It is pulled back toward the middle of the hard palate and may be held firmly against the hard or soft palate. Hard approximation of the tongue with the palate may make insertion of utensils extremely difficult and may make it nearly impossible for any food to be placed on top of the tongue for swallowing. Gagging may be increased for the person with this pattern. Severe tongue retraction can partially block the laryngeal airway contributing to added respiratory problems during feeding. Tongue retraction may be associated with other patterns of retraction or extension in the body (i.e., shoulder retraction or neck extension) or it may be an abnormal pattern used as compensation by a person with poor swallowing patterns. When a person has swallowing difficulties, food which moves rapidly or is very thin may be uncontrollable and life threatening when the tongue is more forward. In such cases, the tongue retracts, resulting in reduction of the size of the pharyngeal opening. This pattern is associated with abnormal increased muscle tone.
  • Asymmetrical tongue placement or movement - The tongue deviates to one side or the other and may show atrophy on the affected side. It may be accomplished by or associated with abnormal tone in the facial musculature. All movements of the tongue are affected. The tongue deviates, or is pushed toward the weak side. If lateral tongue movement is consistently observed only to one side, it may not be active lateral movement, but rather may be asymmetrical movement toward the weak side.
  • Hypotonic tongue - may appear thickened and shows little or no active movement. Fasciculations, small, uncoordinated movements over the body of the tongue, may be observed when the tongue is at rest. These movements may increase during eating, drinking, swallowing and vocalizations.
  • Dystonic tongue movement - rhythmical, nonfunctional movement of the tongue associated with Parkinson's or Parkinson's like symptoms. The ability to interrupt the movement is related to the severity of the disease. With less severe involvement, the pattern can be interrupted during functional activities such as eating or speech, and will not be observed during sleep.
  • Tongue fasciculations - An abnormal pattern of nonrhythmical, unorganized contraction of individual muscle fibers across the surface of the tongue. May be observed when the tongue is at rest, or following direct stimulation to the tongue. May also be observed during generalized hypertonicity or hypotonicity affecting the whole body. Ankyloglossia - A structural impairment consisting of a shortened lingual frenulum. Body of the tongue is thinned, with the lateral borders elevated. A heart shaped indention may be noted at the front edge of the tongue. Function is limited if the tongue tip can lift less than 1/4" above the lower incisors. Pseudo Ankyloglossia - A functional impairment in which the body of the tongue is thickened and retracted. The lingual frenulum appears as a prominent white fiber at the center of the tongue tip. The end of the tongue is blunt and thick.

Jaw Patterns

Normal jaw patterns are presented from less to more controlled. In normal development, these patterns do not develop linearly. In the same person, more mature patterns may be observed with easy to chew foods, (ex: a cookie) and more primitive patterns may be observed with harder to chew items (ex: steak). The primitive patterns do not disappear. More mature patterns are used with foods requiring grinding, while more primitive patterns are used with less viscous foods.

  • Close and hold - Jaw stability and strength are adequate to close around the item with normal muscle tone, but not yet strong enough to allow up and down jaw movement around the item. Do not confuse this normal pattern with tonic bite.
  • Wide jaw excursion - This early pattern is characterized by poor jaw grading in which downward jaw displacement is exaggerated, but not associated with abnormal tone. It is associated with poor internal jaw stability. It may occur during suckling, sucking and chewing. It is often seen during nursing, and then again when cup drinking is introduced. As the jaw gains greater internal stability, better control of jaw movement occurs with improved grading and wide jaw excursions decrease.
  •  Phasic biting - This primitive normal jaw pattern is characterized by rapid rhythmical up and down movement of the jaw. No lateral movement of the jaw is seen. It may occur following stimulation of cheek, gums, or molars. It is usually limited in power.
  • Munching - This early chewing pattern combines phasic biting and some nonstereotypic vertical movements of the jaw with tongue movement to the hard palate. No lateral jaw movement is observed with these five patterns. A person with these patterns would not be able to grind up fibrous foods. Soft, lumpy foods and ground meats are usually the diet tolerated with these patterns.
  • Lateral jaw shift - This is a lateral (side to side) movement of the jaw with no downward displacement of the jaw.
  • Diagonal movement - This is a lateral, downward movement of the jaw to either side with easy contact and release. It aids in the placement of food between molars for chewing. There is no grinding movement, and no movement of the jaw across midline. It occurs in conjunction with vertical jaw movement.
  • Diagonal rotary movement - There is a lateral, downward movement with upward, horizontal sliding movements for grinding foods between molars. The jaw moves to one side or the other, without crossing midline. It may accompany lateral movement of food from the center of the tongue to the teeth.
  •  Circular rotary movement - This is the most mature chewing pattern, with jaw movement laterally, downward, across the midline to the other side and upward to close. It may occur either clockwise or counter -clockwise. It may accompany transfer of food from one side of the mouth across the midline to the other side of the mouth.

Each of these normal patterns may be accompanied by significant muscle weakness. The pattern is observed, but is not efficient for more viscous foods due to lack of power for closing the jaw.

Abnormal Jaw Patterns

Abnormal jaw patterns interfere with eating, drinking and speech. Controlled movement of the cheeks, lips and tongue is also adversely affected by these abnormal jaw patterns. Sometimes the patterns are interpreted by the caregiver as volitional, resulting in an inappropriate response by the caregiver. When these patterns are present, mealtimes take longer. There will be poor control of items placed in the mouth with loss of foods, fluids, medications and saliva. Oral hygiene becomes more challenging to provide, often resulting in poor oral hygiene and resulting in gum problems, plaque build up, tooth decay and loss of teeth. Appropriate handling techniques for mealtime and oral hygiene are needed.

**Do not elicit any of these reflexes.  Simply be observant of them.  

  • Jaw clonus - Rapid, rhythmical movement of the jaw upon closure, indicating weakness or fatigue. May be observed in infants during sucking.
  • Tonic bite reflex - This is jaw closure accomplished by forceful, sustained upward movement of the mandible. It occurs following stimulation of the teeth or gums. It is accompanied by increased abnormal tone in the jaw muscles. It is difficult to release. Damage to the teeth or to the object placed in the mouth may occur. The tonic bite increases if the item is pulled on. Do not confuse this pattern with a bite reflex which results in closing or approximation of closing following stimulation to the lips, gums or teeth. This normal reflex becomes integrated before age two, and is not associated with abnormally increased muscle tone.
  • Jaw thrust - The jaw opens through forceful, sustained downward and outward movement of the jaw (mandible). It occurs following presentation of foods for biting. It may also occur as part of a total body extension pattern. It is accompanied by increased abnormal tone in jaw muscles. Do not confuse this pattern with wide jaw excursions (poor jaw grading), often seen in normal infants. Pressing up on jaw increases the jaw thrust.
  • Jaw retraction - There is a forceful, sustained movement of the lower jaw, carrying it up and toward the back so that the alignment of the molars is displaced. It is associated with an abnormal increase in jaw muscle tone. It may occur following change in body position, or following the presentation of foods, liquids, or medications into the mouth. It may also occur in conjunction with abnormal muscle tone and abnormal patterns of movement. There is less room in the back of the mouth, so swallowing and breathing are more difficult.
  • Dystonic jaw movement - An abnormal pattern characterized by rhythmical, nonfunctional movement of the jaw associated with Parkinson's or Parkinson's like symptoms. The ability to interrupt the movement is related to the severity of the disease. With less severe involvement, the pattern can be interrupted during functional activities, such as eating and speech, and will not be observed during sleep.
  • Bruxism - Bruxism or toothgrinding, may occur for a variety of reasons. In individuals with abnormal oral motor patterns, bruxism may be associated with muscle weakness or with abnormally increased muscle tone. Pressure to the outside of the face is not effective in reducing bruxism. Emphasize on increased internal jaw stability with increased opportunities for closing the molars around chewy objects has been helpful in reducing the incidence of bruxism. Bruxism may increase when an ear infection or fluid in the middle ear occurs. It may also increase with headaches or when there is pain due to gum or tooth disease.

Cheek Patterns

Normal cheek patterns include protrusionretraction, and compression. The cheeks form the walls of the face. The cheek is composed of many layers of muscle tissue, inserting at many different angles. The cheeks assist in repositioning food in the sides of the mouth, in placing food between the teeth for chewing and in moving the food, fluid or saliva to the posterior of the oral cavity for swallowingThe muscles of the cheek assist with lip, jaw, and tongue movement. The receptors for swallowing are located in the posterior area of the cheeks, as well as on the gums, tongue and soft palate. Some of the salivary glands are located in the cheeks.

Abnormal Cheek Patterns

Abnormal cheek patterns include hypotonicity (decreased muscle tone in the cheeks), hypertonicity (increased muscle tone in the cheeks), fluctuating tone, and atrophy due to disuse. These are often seen in combination with abnormal jaw, tongue and lip patterns. Each of these impacts on oral function. If the above patterns exist, there may be decreased awareness of what is happening in the oral area. Control of substances in the mouth will be adversely affected. The level of oral-motor response may change, based on the texture of food presented, or on the type of handling or feeding equipment the caregiver uses.

Drooling

Loss of saliva from the mouth may occur for a variety of reasons. Gum or tooth disease, reflux, upper respiratory infections, allergies, mouth breathing, body position, level of activity or alertness, intensity of concentration, and impaired patterns of movement for the lips, cheeks, tongue and jaw may also result in drooling. Programs emphasizing conscious control of saliva are not effective. Evaluation of all factors affecting saliva control is essential for planning effective interventions to reduce drooling. The opposite also often ocurrs where the pt doesn't produce enough saliva and then has what we call xerostomia or dry mouth.  This can be normal for them. caused by dehydration, certain medications, decrease in oral care, or many other reasons.  Saliva control is vital for the swallowing process and our health.

Gagging

Gagging is a protective reflex. It may be elicited by a number of different stimuli including: olfactory (smell); visual; touch to the posterior third of the palate, inner gums or tongue; touch to the pharynx; stimulation of the vagal nerve in the intestinal track; and stimulation of the semicircular canals in the inner ear   following rapid movement of the head or body. Gagging may also occur if a more functional oral response, such as muscle contraction, chewing or swallowing, is not present due to oral motor impairment. By providing controlled pressure and movement on the face and within the mouth, an individual with oral motor impairment can develop those more functional responses, so that gagging is normalized. The goal is to normalize the gag, not to extinguish it. The gag is necessary for protection of the body from unfamiliar or harmful stimuli.

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Evgenia Stefanaki, SLP, OM, has the private practice "All for Speech Center" and is a nationally certified and licensed Speech & Language Pathologist. She is also PROMPT© trained, oral-motor & feeding specialist and holds specialization in orofacial myofunctional therapy. 

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