Food Refusal - Is It Oral Motor or Sensory Related?
Posted by Debra C. Lowsky, MS, CCC-SLP on 10th Nov 2014
Having a child with feeding issues is one of the hardest problems to handle both for therapists and parents, and it's stressful for the child as well. Our lives often revolve around food! And so does healthy growth and development. I commend you for looking for more information on this topic and hope that you find this post helpful. So, take a deep breath and let’s roll up our sleeves.
Before we begin, please keep in mind that only a speech language pathologist (SLP) who can evaluate your child in person will be able to tell you why he/she is refusing foods. If you are concerned that your child has eating problems, please consult with your pediatrician and ask for a referral to see a SLP with feeding experience. If it's sensory-related, you’ll likely want/need an occupational therapist (OT) involved as well.
In the meantime, I can tell you that the children who I see with feeding issues typically fall into one of two categories (or a combination of the two): oral motor issues and/or sensory issues. Below is some information that you may find helpful, along with strategies that have proven successful with the children I personally see and treat (assuming that all medical issues, such as reflux, GI problems, medication side effects, etc. have been ruled out and/or managed already):
Some children pocket, refuse, gag, vomit, or spit out food because they know they don’t have the oral motor skills to properly manage the food. Although eating is very second nature / automatic for most of us, it’s actually very involved. The jaw moves in a rotary motion to chew and adequately break down the food. At the same time, the tongue manipulates food from side to side and up and down to assist in breaking down the food, ultimately forming the food particles into a bolus in preparation for the swallow. It’s complicated! It requires tongue lateralization, tongue elevation, jaw strength, rhythmic chewing, coordination, etc.
If a child is behind on any of these oral motor skills, then eating can actually be dangerous and some foods a choking hazard. In my experience, many children know that they can’t handle the food, so they refuse it as a self-defense mechanism. The child just may not be able to communicate this very real fear of foods he/she can’t chew.
Usually a tell-tale sign of an oral motor feeding delay is the lack of tongue lateralization. Can the child move their tongue from one side of the mouth to the other and vice versa? Can the child elevate his/her tongue tip to the alveolar ridge (the gum area just behind the top front teeth)? How does the child chew? Does the jaw move straight up and down or does it move in a circular/diagonal motion? Is the child chewing the food enough? Take a bite of whatever the child is eating and count how many chews it takes you to break the food down. Then count and see how many chews the child takes. He/she should have tongue lateralization and elevation (without moving the head to assist), a mature chewing pattern, and enough chews to adequately break down the food. If not, check out this post on how to develop a rotary chewing pattern. You may also find some things that "ring a bell" in other areas in our blog's oral motor category.
The sensory spectrum is a vast and complex one, but typically I see sensory food aversions present in one of two ways (or again, sometimes a combination of them):
- Hypo-sensitivities, meaning little to no oral awareness. When there’s not enough oral awareness, you may see some mouth stuffing (also known as food pocketing) - sometimes children do this in an attempt to better “feel” the food in their mouth. Other times you may see an issue with leftover food particles on the tongue, lips, inside cheeks, etc. - if the child can't feel them in the mouth, he/she won’t know to retrieve and swallow them. In some cases the child may also drool because of the lack of sensation (you must be able to feel the saliva pooling in order to know you need to swallow).
- Hyper-sensitivities, meaning too much oral awareness. In this case, the child may gag or vomit, spit the food out, turn away from the food, resist by crying/kicking/screaming, present with a range of behavioral issues, etc.
I highly recommend gum massage for both. And this post on oral defensiveness goes into the above in more depth, as well as strategies on how to normalize both.
When working with oral sensory aversions, I don't ask children to eat the food right off the bat. They may eat or taste it, but that is not the goal right now. First they need to become comfortable with food, which is a gradual process. What I do is introduce foods through play. Let them manipulate food by making faces out of it, smashing it, rolling, drawing, stacking, etc. Your OT can also have them play in bins of rice to find hidden objects such as plastic animals/bugs/objects. Macaroni (uncooked) comes in lots of shapes and textures so they would be good. You can play with shaving cream, make mud pies, hide objects in a bucket of rice, etc. - all to get them used to touching all kinds of textures. The palms of the hands are sensitive to touch, which is related to oral sensations. So begin with the palms and fingertips to work towards acceptance of different foods / sensations in the mouth. Click here to learn more about why food play can be beneficial.
It’s also important to note that sometimes sensory issues mask oral motor issues. So once you’ve normalized sensitivities, you may need to refer back to the first half of this post. More often you will see oral motor issues present with children who have hyposensitivities than with hypersensitivities. . All of this takes time AND it does get better. Remember, though, that everyone has their own food quirks. Think of how a person drinks his/her coffee. My husband likes a little coffee with his cream, mixing it together until it turns a certain color light brown color. Others like their coffee black, or with sugar, or with sweet and low, etc. For me, I don't like the smell of coffee. Never had a cup in my life. I don't like kiwi or avocado - they are too mushy and slimy. All of the above preferences are sensory-related. A lot of the time they stay just that - as preferences - and don’t become a feeding problem. So it’s okay if your child simply doesn’t like certain food items. The goal is just to have a well-rounded diet eating from all of the food groups. . And again, I can’t stress enough the importance of having a speech / feeding therapist guide and help you. A dietician would also be a good idea to make sure the child is getting the necessary nutrition while the feeding issues are still being managed.
I hope you find this information helpful!
Debra C. Lowsky, MS, CCC-SLP