Feeding Development and Difficulties

Physical, Sensory and Oral Motor Development

  • Physical, Sensory blue puzzle piece

    • Learning to eat parallels physical, sensory and oral motor development. It is supported by repeat experiences but is not taught.
    • During the first 2 years of life, evolving patterns for gross motor, fine motor and oral motor development function as predecessors to subsequent development of self-feeding skills that in turn affect nutritional intake and growth of infants. (Carruth and Skinner 2002)

    Exclusive breast or formula feeding

    Newborn

    • Gross motor and oral motor movements are characterised by involuntary primitive reflex actions.
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    • Posture is in a flexed curled up position with hands clenched.
    • Amniotic fluid has exposed baby to taste and smell.
    • Innate preference for sweet tastes such as breast milk.
    • Can focus at a distance of 20- 30 cm.
    • Responds to touch e.g. skin to skin contact, patting.
    • Range of tongue movements is restricted to a forward - backward pattern as the space in the mouth is limited.
    • Large buccal fat pads or cheeks act to support and stabilise the nipple or teat entering the mouth.

    When feeding:

    • Baby is:
      • Dependent on the carer for postural stability.
      • Supported in a reclined position, with full support of the head, trunk and limbs. The head is positioned in the midline with a slight chin tuck.
      • Able to focus on the mother’s face. (Distance is approx. 30 cm)
    • Rooting, Suck-swallow, Tongue thrust and Gag reflexes work together to enable the infant to locate and attach to the breast or bottle to feed while also protecting against airway penetration.

    During the first few months of life

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    • Trunk and head control develop. Head can be held up and in the midline for short periods.
    • Clenched hands unfold and movements become purposeful. Hands are able to come to midline for play.
    • Breast feeding exposes baby to a variety of flavours influenced by the mother's diet.
    • Mouthing of hands, clothes and toys provides sensory experiences.
    • Tongue thrust and rooting reflex begins to integrate.
    • Range of tongue movements increases.
    • Oral motor skills develop as mouth is used to explore hands and toys preparing for new feeding experiences.

    When feeding:

    • Baby:
      • Is positioned with support around the head, trunk and pelvis to provide a stable base.
      • Is able to tuck their chin and is in a slightly more upright position.
      • Begins to turn head purposefully to the breast or teat and actively sucks to feeds.
      • Recognises the smell of mother.
      • May bring their hands to the breast or bottle.

    First Foods

    • Guidelines for the introduction of solids are based on developmental readiness and increasing nutritional requirements. For most babies this is around 6 months.
    • Babies vary in the age at which they are developmentally ready for first foods.
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    • Postural control and internal stability increase enabling baby to:
      • Sit with support in an upright position.
      • Rotate trunk and head voluntarily.
      • Bring hands and toys to mouth for exploration.
      • Use whole hand to grasp objects (palmar grasp) such as toys.
      • Able to roll over.
    • Feeding in a 'very' reclined position is no longer safe, due to the risk of aspiration.
    • First foods provide new sensory experiences.
    • Body movements such as, head turning, facial expressions are used to respond to sensory stimuli.  Responses may be open to interpretation.
    • Tongue thrust may still be present but has diminished.
    • Range of tongue movements increases to include up and down movements.
    • Suck and swallow are differentiated –food can be taken into the mouth, held and then swallowed voluntarily.
    • Gag reflex moves to back third of the tongue.

    Signs of readiness for first foods:

    • Good head control.
    • Mouths hands and toys independently.
    • Able to sit in an upright position with support either on the lap or in a suitable high chair.
    • Tongue thrust has diminished.
    • Opens mouth when food is offered.
    • Enjoys watching others eat.

    Signs of developmental readiness are a better indicator than age.

    Increasing variety

    • The types and textures of food that can be managed parallels physical, sensory and oral motor development.
    • Graded experiences give confidence to progress with advancing textures.
    • Increasing variety also coincides with desire for feeding independence.
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    • Control and stability of the head and trunk continues enabling baby to:
      • Become more mobile.
      • Sit unsupported. Suitable seating for feeding provides support of hips, knees and feet at 90 degrees – referred to as 90-90-90 position.
      • Reach purposefully to grasp and bring finger foods to the mouth.
      • Transfer food from hand to hand.
      • Use pincer grip to self-feeding of smaller pieces of food.
      • Use hands and utensils to explore food and develop skills in self-feeding.
    • Understanding of sensory concepts such as warm- cold, rough- smooth develop.
    • Multiple experiences with the same taste and texture increase acceptance of new foods.

    Oral-motor skills develop supporting progression of food textures  

    • Tongue lateralisation develops
      • Able to move food from side to side in the mouth. 
    • Differentiation of tongue and jaw movements develops to enable:
      • Diagonal rotary chewing.
      • Munching pattern of jaw movements.
    • Jaw stability develops to enable:
      • Improved spoon feeding control.
      • Drinking from an open cup but relies on parent for help with holding and tipping.
    • Lips - needed for control of food and to maintain the bolus in the mouth.  

    At mealtimes:

    • Children are able to sit unsupported, typically in a high chair that supports pelvic and trunk stability.  A tray or table that supports the hands and elbows promotes self-feeding.
    • Seating position that allows for eye contact with parents and others sharing the meal promotes social interactions.
    • Children are offered an increasing variety of foods of varying textures.

    Side note: Dental development

    The age at which teeth erupt is variable. While the presence of teeth enables chewing to be more efficient children who are late to develop teeth can still progress with the development of oral-motor skills though the provision of graded experiences.

    Independent feeder

    • Skills for self-feeding are refined as gross and fine motor skills are consolidated.
    • Oral-motor skills develop to enable foods with a wider variety of textures to be managed.  
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    • Mobility increases as children develop the ability to:
      • Walk independently.
      • Complete all transitions including getting on and off a chair independently.
    • Arm, wrist, hand and finger movements disassociate enabling refining of:
      • Hand-eye coordination supporting self-feeding.
      • Correct and efficient use of feeding utensils.
      • Skills in serving and preparing food e.g. spreading bread, pouring a drink.
    • An increasing variety of tastes and textures is managed and enjoyed.
    • Smell or appearance of food may be associated with perceived taste.
    • Typically displays some apprehension in trying new foods.

    But

    • Gradually increases willingness to try new foods – uses sensory stimuli to assist with food choices.
    • Movements of lips, teeth, tongue and jaw are coordinated to achieve more efficient feeding.
      • Size of bite is graded.
      • Food is transferred to the teeth (or gums) for chewing.
      • Rotary chewing movements are used more frequently.
      • Lips keep mouth closed while chewing.

    At mealtimes:

    • Mess reduces as self-feeding skills are refined and chewing becomes more efficient.
    • Children are able to position themselves independently during mealtimes in a variety of settings including on the floor, small tables and chairs or at the dining table.
    • Assistance to cut harder foods may be required.

    Further Reading:

    Carruth, B.R. and J.D. Skinner, Feeding Behaviors and Other Motor Development in Healthy Children (2–24 Months). Journal of the American College of Nutrition, 2002. 21(2): p. 88-96.

    Redstone, F.W., J F.  The Importance of Postural Control for Feeding. Pediatric Nursing;. 30(2).

    Suzanne Evans Morris Website

    Changing the Physical Environment