Understanding Mealtime Skills
Supporting Children With Disabilities at Mealtimes
"No single activity is as critical to the health, education, and happiness of children with disabilities as feeding." (Lowman, 1999)
Mealtimes are important for each and every one of us. Mealtimes play a significant part in the growth and development of children and youth. Mealtimes are typically a time when an individual's nutritional needs are met in order for good growth and development to occur. They are also a social time where communication, sharing and being together takes place. Mealtime skills can also be an important part of the student's educational program to help prepare them for more independent or participatory living.
In normal development, a vast majority of how a child learns to eat and drink takes place in the first 3 years of life.
There are some basic developmental principles to consider prior to looking in depth at the stages of oral motor development (development of patterns of movement in the mouth). These principles are as follows:
- Development occurs in a predictable sequence.
- Gross movement patterns are learned before fine skilled movements.
- Early development is "sensory/motor" in nature. The sensory and motor systems work in concert with one another giving continual feedback.
There are also four factors, which are common to all age groups. They are as follows:
Rhythmicity is a child's ability to produce rhythmic movement patterns. Rhythmicity is a vital part of successful feeding and continues through each stage of development, until that child is able to use rhythmic movement patterns in an organized manner.
Stability is the child's ability to hold the body steady. The establishment of stability is the precursor to the development of coordinated and organized movement patterns.
Separation of movement is the ability to move one part of the body without moving other parts. As the child's stability increases, there is the opportunity of greater separation of movement which allows for the development of more mature patterns to take place.
Movement options are enhanced when there is rhythmicity, stability and separation of movement. The establishment of these skills gives the child options for performing physical activities in more than one way. Movement options also allow the child to experiment with different ways of dealing with unfamiliar oral motor tasks.
The following table shows typical development of oral motor skills and their relationship to food textures and what the child can manage to eat and drink. Remember that all children develop at their own rate. Children with disabilities may not advance through all these stages (becoming stuck at one particular stage) or they may advance more slowly, taking longer at each stage.
Normal Infant Development and Feeding Skills
Age |
Oral Motor Skills |
Child Can: |
birth to 5 months |
suck/swallow reflex |
- swallow liquids but pushes most solid objects from the mouth |
4 through 6 months |
draws in upper or lower lip as spoon is removed from the mouth; up and down munching movement; can transfer food from the front to the back of the tongue to swallow; tongue thrusting and rooting reflexes begin to disappear; gag reflex diminishes; opens mouth when spoon approaching |
- take in a spoonful of pureed or strained food and swallow it without choking |
5 through 9 months |
begins to control the position of food in the mouth; up and down munching movement; positions food between jaws for chewing |
- begin to eat mashed foods
- eat from a spoon easily |
8 through 11 months |
moves food from side to side in mouth; begins to curve lips around rim of the cup; begins to chew in rotary pattern (diagonal movement of the jaw as food is moved to the side or center of the mouth) |
- begin to eat ground or finely chopped food and small pieces of soft food |
10 through 11 months |
rotary chewing (diagonal movement of the jaw as food is moved to the side or center of the mouth) |
- eat chopped food and small pieces of soft, cooked table food |
USDA/Food and Nutrition Service. Infant Nutrition and Feeding. 1993
A majority of oral motor skill development occurs between the ages of birth and 11 months as noted above. However, between the ages of 12 months and 3 years the child continues to refine and improve those skills developed earlier. This allows for longer drinking sequences, and safer management of a wider variety and range of foods.
By a very early age, mature feeding patterns have developed which will continue for life. The intense and varied sensory experiences during the first year of life are vital to establishing a good foundation for oral motor development.
Texture plays a critical role in how easy or difficult a food can be for a child to eat safely. "Texture" is how smooth, lumpy, thick or thin the food is. The following table describes different textures and what a child can usually do in order to handle the texture.
Textures Which Commonly Cause Problems
- Thin Liquids - Some children may have trouble swallowing thin liquids, so they will need to be thickened. Thin liquid moves rapidly in the mouth and gives less sensory feedback versus thickened liquid. Thickened liquid moves slowly, and gives more sensory feedback, thus making it easier for the child to coordinate muscles in the mouth and swallow.
- Dry or Lumpy Foods - Dry or lumpy foods can be difficult for some children to manage safely. These foods may elicit a gag response or trigger coughing and or vomiting. Pureed fruits such as applesauce or pureed vegetables can be given between bites of dry or lumpy food; or they can be used as a "dip" for dry foods. Some children will not be able to safely manage foods that are dry or lumpy and may require a pureed diet.
- Multi-textured Foods - Multi-textured foods are foods that have a thin liquid mixed with solids, such as soups and some stews. These types of foods can be difficult for some children to organize in their mouth in preparation for swallowing, putting them at risk for choking and or aspiration.
- Foods That Do Not Dissolve - Some solid foods do not dissolve in the mouth and require rotary chewing skills in order to prepare them sufficiently for swallowing. These foods would include items such as raw fruits and vegetables.
Food Texture and Eating Skills
Texture |
Description |
Example |
Child Can: |
Level 1 -pureed and blended table foods, commercial baby food approximately 4 -6 months of age |
food forms a paste or thick liquid; use strainer or blender and blend to a paste, add liquid for desired consistency: no lumps |
iron fortified infant cereals with breast milk, formula or water; vegetables and fruits |
use suck/swallow pattern; take food from spoon, with lips; lips and jaw closure; swallow thickened purees and not gag; |
Level 2 - mashed lumpy, thickened pureed foods approximately 6-9 months of age |
food forms a heavy bolus; food is blended or mashed with a fork; may have some small soft lumps; food retains some texture and consistency |
mashed potatoes; blended meats, chicken and tofu; mashed bananas and other soft fruits; mashed hard cooked egg yolk; mashed carrots or squash; well cooked and mashed legumes (beans, peas and lentils) |
handle food through sucking action and cannot move food to sides of mouth; swallow without gagging; close lips while swallowing food; remove food from spoon with lips; beginning up-and -down jaw and tongue movements (munching) |
Level 3 - ground/minced approximately 9-12 months of age |
food ground in food chopper, not blended; food retains some lumps for chewing; 1/8" pieces to 1/4" pieces; food should be easy to chew |
crumbled/ground meat; tofu; scrambled egg yolk (egg whites at 12 mos.); cottage cheese; small pieces of toasted bread crusts; crackers broken into small pieces |
demonstrate up-and-down jaw and tongue movements (munching); begin to chew in rotary pattern |
Level 4 - chopped approximately 12-18 months of age |
cut with knife into bite size pieces; 1/4" pieces to 1/2" chunks; no raw hard foods (carrots) |
chopped fruit (soft raw or cooked); chopped meats; chopped cooked vegetables; grilled cheese or finely chopped meat sandwiches; finely chopped salad or slaw |
perform side to side movement of the tongue, vertical and diagonal jaw movements with enough strength to break up the pieces; do rotary chewing |
Level 5 - regular approximately 18+ months of age |
needs to be cut or bitten in order to be eaten |
all foods |
close lips and keep food in mouth; bite through food |
Preparing Food For Meals And Snacks
Some children have difficulty managing specific textures of food or they may have difficulty in transitioning from one texture to another. Deciding on which texture best suits the child involves assessing the oral motor skills the child currently demonstrates and matching those specific skills to a suitable texture and consistency of food. In general, the higher the texture (refer to previous tables) the more skills required in order to manage eating/drinking safely. Consistency refers to the amount of moisture contained in a food/liquid. To change consistency you can add fluids, fats or condiments. Both texture and consistency need to be appropriate and matched to the child's oral motor skill level. Refer to charts below.
Note: Avoid the use of hard, small and round, smooth and sticky solid foods (e.g. popcorn, hard candies, gum, cough drops, raisins, nuts etc.) with young children (under the age of 4 years), as well as older youth who demonstrate immature oral motor patterns. The above items are considered unsafe and can block a young child's airway. The following foods are safe for infants and young children when they are prepared as described: weiners diced or cut lengthwise, grated raw carrots or hard fruit pieces, chopped grapes, and peanut butter spread thinly on crackers or bread.
Choking And Aspiration
The risk of choking can be lowered when care providers are aware of the child's eating and drinking abilities, avoid offering foods/liquids which have the potential to cause choking and know how to handle choking if it occurs.
Oral Motor Patterns and Consistency
Consistency |
Examples |
When a Problem |
sticky |
potatoes, rice, pastas, other starches |
weak or poorly coordinated tongue movements, dry mouth, thick saliva, hypersensitivity to pressure and movement (food can stick to the roof of the mouth or the back of the throat leading to coughing or gagging) |
dry |
meats, bread, crackers |
weak or poorly coordinated tongue movement, thick saliva, dry mouth (food may wad in the roof of the mouth leading to coughing or gagging) |
wet (slippery) |
chopped foods (spinach, peach, banana) |
weak or poorly coordinated tongue movements, thick saliva, slow to swallow (wet food may come out of the mouth or move back too quickly for the person to control) |
runny |
pureed fruits or vegetables with lots of liquid |
weak or poorly coordinated tongue movements, thick saliva, slow swallow (runny food may move too fast for the person to control) |
References
British Columbia Ministry of Health, Feeding Your Toddler with Love and Good Food, Handout, 1994.
British Columbia Ministry of Health, Baby's First Foods, Handout, 1995.
Isaaca, J., Cialone, J., Horsley, J., Holland, M., Murray, P., and Nardella, M. Children With Special Health Care Needs: A Community Nutrition Pocket Guide, Library of congress Catalogue card No. 97-68296, 1997.
Lowman, D., Murphy, S., The Educator's Guide to Feeding Children With Disabilities. Paul Brooks Publishing, 1999.
Ministry of Public Works and Government Services Canada, Nutrition for Healthy Term Infants, Ottawa, 1998.
Morris, S.E., Klein, M.D. Pre-Feeding Skills. Therapy Skill Builders, Tucson, AZ. , 1987.
Oklahoma Department of Human Services, Mealtime Challenges. Therapeutic Concepts Inc. 05101091
Project CHANCE, A Guide to Feeding Young Children with Special Needs. Arizona Department of Health Services Office of Nutrition Services, 1995
Shaddix, T. and Barncastle, N. Oral Motor Development and Feeding Techniques. United Cerebral Palsy of Greater Birmingham, Inc. 1986.