I recently completed a Clinical Swallow Evaluation and today a Videofluoroscopic Swallow Study of a 10 yr old boy's swallow (both revealed a safe swallow that is within normal limits) and observed that his is not an age-appropriate chew pattern. He engages in a Nonstereotypic Vertical Movement during mastication. As a result, oral prep phase is significantly extended and his mother reported that it takes him (at times) up to 1.5 to 2.0 hours to complete a meal. In one case, he informed me that he does not like powder (i.e., flour or powdered sugar) and the meal in question consisted of scrambled eggs and French Toast that had only powdered sugar on it - sans syrup. However, I have found no information regarding immature mastication patterns in older children. Any information or resources you may provide or suggest in this regard will be greatly appreciated.
In a vertical chewing pattern, the jaw moves up and down in a vertical motion. Since the tongue and jaw are connected, the tongue will follow suit, also moving up and down. This is sometimes referred to as a "tongue pump."
On the other hand, in a mature chewing pattern, the jaw moves in a rotary (circular) motion to grind the food - imagine a cow chewing its cud as an exaggerated example. At the same time, the tongue moves from side to side in order to manipulate the ground food particles into a bolus (ball of food). Without this grinding motion and tongue lateralization, it makes sense that he's having difficulties breaking down and manipulating his food, and why mealtimes are very long and exhausting. Try chewing your food today without moving your jaw or tongue from side to side - it's not easy!
So your goal would be to develop a rotary chew so that he can properly chew and manage food. Once his chewing skills improve, he'll be able to eat different kinds of foods, particularly those requiring good chewing ability. And a rotary chew will drastically decrease the time needed to properly break down food, which is typically no longer than 30 minutes.
Now, how do you develop a rotary chew? It's hard to know exactly what will work without seeing the child, as each child is different and intervention must be modified accordingly after assessing their needs in person. But in my experience, a combination of the strategies below have been successful in promoting a rotary chewing pattern:
- First check for correct positioning as he sits at the table. His back should be flat against the back of the chair with his feet firmly planted on the floor. You can put a box under his feet if necessary. A consultation with a physical therapist may be necessary if he doesn't have good trunk support, trunk turning skills, etc. You are teaching the mouth muscles to work properly, and the rest of the body needs to support this.
- To establish the concept of tongue lateralization, do trunk turning exercises with him. You can also physically push or guide the tongue over to one side with either the oro-Navigator or the Probe. This provides a tactile cue to help him feel where his tongue should be going - sometimes just telling or demonstrating is not enough.
- Begin working on tongue lateralization exercises. Stroke the sides of the tongue with the Probe or Z-Vibe to stimulate lateralization. Stroke one side five times, then the other. Then alternate sides to simulate back and forth movement.
- You can also place the tip of the Probe, Z-Vibe, or Grabber inside the cheek area to one side. Have the child touch it with the tip of his tongue. Repeat to the other side. Do about 5 sets. Dip the tool in a bit of peanut putter (or any sticky food that he likes) to make this activity more motivating.
- When you feed him with a spoon, don't always put the food in the middle of the tongue. Put it to the left and to the right to challenge him and make that tongue move.
- Encourage him to chew on a Grabber or Y-Chew. As non-food items, these chew tools are a safe way to practice chewing without the risk of choking on real foods that he can't manage yet. Not only is the risk of choking a concern for obvious reasons, but it can also cause children to develop anxiety over food. So it's best to use a chew tool in the meantime until his oral motor skills improve.
- Have him bite and chew the Grabber or Y-Chew 3-5 times on one side of the mouth. Then switch to the other side. Repeat several times on each side. Alternating sides will help encourage a back-and-forth motion.
- It may also be important to build jaw strength and stability.
With continued practice, the tongue will start moving from side to side and the jaw in a circular pattern. Please keep in mind that this may take a long time. Have patience!
In the meantime, think of this oral motor delay as you would a language delay. When you test a 10-year-old at a 3-year-old language level, you back up and start working on the skills a 3-year-old would start learning. It's the same thing for feeding. Even though he's 10-years-old, he's not where a 10-year-old should be in terms of his chewing abilities. So you can't feed him at a 10-year-old level.
Have mom take an inventory of everything that he eats for about 3 days, making notes about the foods and how easy/hard they were for him. This will give you some history, and you can make adjustments / downgrade from there to foods that are easier to chew (try the foods yourself to make sure that they are easy to chew and break down quickly). I would even recommend that you go back to what babies eat at about an 8-9 month old age level. Use that as a baseline and build foods from there. Please also consult a feeding therapist AND a dietician. He is growing, and the intake of food must support his growth.
As far as the powdered foods you mentioned, I would stay away from them in a dry state. They're extremely fine food particles, which can be difficult to manage in my experience. And if some of the particles are breathed in as he eats, they could actually cause him to cough and gag. I personally avoid powdered sugar for this reason, as it makes me gag and sneeze.
For more information on chewing patterns, you can consult Pre-Feeding Skills, A Comprehensive Resource for Feeding Development (particularly pages 54-55) by Suzanne Evans Morris, PhD, CCC-SLP and Marsha Dunn Klein, MEd, OTR/L. It is THE go-to book for feeding.
Best of luck!
Debra C. Lowsky, MS, CCC-SLP