This informative guest blog post is courtesy of Lori Nachtigal-Rothschild, MS, CCC-SLP.
Question: What are the most important skills for chewing harder foods? Answer: Tongue-jaw disassociation (separation) and jaw pressure (aka jaw strength) are the 2 most important skills for breaking down harder foods like carrots, celery, and harder meats.
Before we get in to some treatment strategies for children who have plateaued and not progressed to chewing harder foods, let’s review some developmental stages:
- By 12 months of age, we should begin to see the tongue and jaw separate (tongue-jaw disassociation). Now, the tongue will not just follow the jaw for up and down movements, but will also separate from the jaw. The tongue will move laterally as diagonal jaw movements begin to emerge (Morris and Klein 2000). We can observe a child moving a soft food piece of food (cheerios, cooked fruits, bananas, soft cooked veggies, moist cooked noodles, slightly mashed beans) across midline of the tongue, to one side. We can see active lip and cheek movement. Foods presented at this age easily form a soft ball in the mouth.
- By 15 months of age, we begin to see a young child move a food piece across midline (of the tongue) to the other side, with lips actively closed during chewing. The jaw uses rotary diagonal movements, with continued refinement and fluidity, throughout the 18-36 month period. At this time, a child can do multiple side to side chews, with rotary jaw movements, to break down (or grind into small pieces) a hard food (i.e. celery, hard chicken nugget) and bring it back in to a bolus (a solid piece), for swallowing. Also, by 24 months a child will typically know how much jaw opening and pressure is needed to bite off a hard piece for chewing.
Without the above skills, children may fatigue and begin to self-limit their diets to softer food textures.
Typically, feeding is labeled a problem when a child becomes “stuck” in a pattern for a considerable period without progression (Eicher, 2002; Kerwin, 2003). A child’s diet may become limited in a way that results in a Physician and/or caregiver developing concerns for nutrition and weight gain. When these concerns arise, parents should be referred for a thorough evaluation, by a Speech Pathologist or Occupational Therapist, who specializes in Feeding and Oral Motor. A thorough oral motor assessment of structure and function may reveal contributing factors such as low muscle tone, poor oral coordination of musculature, sensory-motor deficits, and/or structural issues such as tethered oral tissue (tongue tie).
Challenges to Feeding Therapy:
As a Feeding Therapist specializing in early intervention, working with children under 3 presents with a unique set of challenges. Typically, these children do not have the readiness to follow task specific verbal instructions such as “pull with your lips” (for a straw); or “use your tongue to move the food piece to the side” (for chewing). Following visual models can also be a challenge.
As a result, tactile supports are frequently introduced. These type of cues are used to guide the position and movements of oral muscles. In young babies this may include supporting the jaw and cheeks during bottle feeds. In older babies this may include similar supports during spoon feeds. We may also want to change or adapt devices such as reducing a nipple size to control liquid flow in a bottle, or adding a Lip Blok and/or One-Way Straw to assist in straw drinking.
Assisting the Transition to Harder to Chew Foods:
Teaching toddlers to chew and accept new foods can be the most challenging. In fact, when children have persistent food refusals and do not accept new foods, often it's because they have difficulty chewing. So how can we assist with developing more advanced chewing? Work on the oral motor skills required for chewing harder foods, such as jaw-tongue disassociation (separation) and jaw strength/stability. The addition of oral motor devices such as the Y-Chew can be a helpful first step in teaching these skills:
- With the soft/standard level Y-Chew (light blue or yellow), try to stabilize the jaw at the premolars while encouraging movement of the tongue laterally to “touch” the device.
- One can dip the Y-Chew in a sticky substance, or spread, to encourage this skill.
- Also, try to encourage 5 repetitions on each side to build jaw strength (and slowly increase repetitions as you build cooperation and trust).
- Using chewy devices is also a helpful first step for teaching skills in selective eaters that refuse to try new foods. Since a behavioral approach to food acceptance can be slow, this gives something to providers and families to easily implement, in a non-threatening way.
- The ARK Guitar and ARK Grabbers are also helpful first tools for chewing. Many children like using these independently as “teethers”.
- Even in independent use, multiple side chews using the long stem will build strength and stability of the jaw, while encouraging tongue lateralization.
- In therapy, for a child with weak jaw stability, and lateral jaw sliding, one can encourage the child to bite down on both sides of each loop, simultaneously, to build bilateral symmetry.
- Multiple repetitions are encouraged to build jaw strength needed to bite through harder food textures (i.e. harder meats and poultry, many raw vegetables, and harder fruits).
It is also important to note that a strong jaw, with good tongue-jaw disassociation, is an important foundation for fluid intelligible speech.
Lori Nachtigal-Rothschild, MS, CCC-SLP
Lori has a Master's Degree in Speech Language Pathology from Teachers College-Columbia University. She has worked for over 20 years specializing in Pediatric Speech and Feeding disorders. Lori has also served as a Clinical Supervisor and Quality Assurance Manager for several New York City agencies. Lori recently published a children’s book on selective eating, titled “Picky Patty Learns not to Be so Picky”.